
Oass. 



Book 



COPYRIGHT DEPOSIT 








A 




The actual effect of oxygen upon the color of human blood, forming the basis for the Author's 
hsemoxometer (oxyhaemoglobinometer) 



THE ART 

OF 

ANAESTHESIA 



BY 

PALUEL J. FLAGG, M.D. 

UECTURER IN ANAESTHESIA, COLLEGE OP PHYSICIANS AND SURGEONS, NEW YORK; CONSULT- 
ING ANAESTHETIST, BELLE VUE HOSPITAL, JAMAICA HOSPITAL, ST. JOSEPH'S HOSPITAL, 
YONKERS; VISITING ANAESTHETIST, ST. VINCENT'S HOSPITAL, NEW YORK. FOR- 
MERLY LECTURER AND DEMONSTRATOR IN ANAESTHESIA, ROCKEFELLER 
INSTITUTE WAR DEMONSTRATION HOSPITAL. VISITING ANiESTHE- 
TISTTO ROOSEVELT HOSPITAL, THE WOMAN'S HOSPITAL AND 
FORDHAM HOSPITAL, NEW YORK CITY 

THIRD EDITION REVISED 

136 ILLUSTRATIONS 




PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 



>XM 8 \ 



COPYRIGHT, I9l6, BT J. B. LIPPINCOTT COMPANY 
COPYRIGHT, 1919, BY J. B. LIPPINCOTT COMPANY 
COPYRIGHT, 1922, BY J. B. LIPPINCOTT COMPANY 



Electrotyped and Printed by J. B. Lippincott Company 
At the Washington Square Press, Philadelphia, U. S A. 



DEC -1*22 

©CH692169 

MO { 



To 
I. H. S. 

My Dearest Master 

this BOOK 
Is Humbly Dedicated 



PREFACE TO THE THIRD EDITION 

With a view of bringing the present edition up to date, 
the entire text has been carefully re-read with the result 
that deletions, corrections and additions have been freely 
made. Since the appearance of the first edition in 1916, 
the author has been much interested in the question of the 
color sign. The need of a clinical measure of cyanosis is 
obvious to those familiar with operating-room work. To 
speak of cyanosis without being in a position to refer to 
its degree is to make ourselves unintelligible. To speak 
of a definite percentage of cyanosis, or oxygen unsatura- 
tion, is an entirely different thing. As all tissue color de- 
pends upon the color of the circulating blood (pigmentation 
alone excepted ) the blood has formed the criterion for our 
investigation. The absence of cyanosis, or complete oxygen 
saturation has formed one end of our scale ; complete cyan- 
osis or complete oxygen unsaturation has formed the other. 
The blood escaping from the fresh wound of incision sup- 
plies the basis for our readings. At the present writing 
an investigation is being made into the opacity presented 
by the skin and mucous membranes. An instrument has 
been devised called the "h,emoxometer," or, oxyh^m- 
oglobinometer," which affords a simple clinical means 
of reading the oxygen content of the blood. While 
this instrument has just appeared, and has not yet 
been in extensive use, nevertheless, the author does 
not hesitate to recommend it, because of the fundamental 
truths which underly its construction. All of the oxygen 
quantitative determinations were made at the Rockefeller 
Institute through the courtesy of Doctor D. Van Slyke. 



vi PREFACE TO THE THIRD EDITION 

While the present form of this device will, doubtless, 
change, the facts upon which it is based are permanent. 

It is the author's opinion, that the wide spread use of 
gas and oxygen has passed its peak, at least, in the Eastern 
portion of the United States. There is a distinct reversion 
to the oldest, and most trustworthy of anaesthetic agents, 
ether. With this situation in mind, a section has been in- 
cluded, entitled, " General observations based upon ten 
years' experience with Nitrous Oxide Oxygen as an Anaes- 
thetic." One of the most disturbing facts associated with 
Gas Oxygen Anaesthesia are the deaths which have occur- 
red through its use. Some of these have been reported, 
must of them have not. 

In the author's experience, chloroform has completely 
given way to ether administered by intrapharyngeal meth- 
ods. This condition holds, with the single exception of 
oral cases in which the actual cautery is used. 

In attempting to convert the rather old-fashion terms, 
acapnia, hypercapnia, etc., into the more modern views of 
low alkaline reserve, buffer salts, etc., the author finds him- 
self nonplussed. He confesses a rather hazy understand- 
ing of acidosis and alkalosis, but, is entirely unable to offer 
these in the tabloid form which the available space de- 
mands. Inasmuch, however, as our original theories in 
regard to carbon dioxide in its role as a respiratory stimu- 
lant have not been refuted, and inasmuch as our practical 
experience daily tends to confirm these views, we may be 
pardoned for omitting a detailed consideration of the last 
analysis of the phenomena which we observe. 

Paravertebral, conductive or regional anaesthesia has 
been much in vogue. It has been pointed out that the 



PREFACE TO THE THIRD EDITION vii 

enthusiam with which this form of local anaesthesia has been 
received in some clinics is an indication of the inability of 
such a clinic to secure all that general anaesthesiahas to offer. 

Synergistic anaesthesia has been briefly referred to and 
status lymphaticus has been noted. The chapter on 
" the patient's viewpoint " was so well received, that 
the author was constrained to prepare a small volume on 
this subject. 

The author wishes to take this opportunity to thank 
his many friends for their interest and forbearance and to 
express his appreciation for the unfailing courtesy of 
his publisher. 

P. J. F. 

410 East 57th Street 



PREFACE TO THE SECOND EDITION 

The original purpose of this little volume "as a 
groundwork upon which the student, interne, and general 
practitioner may acquire a more comprehensive knowl- 
edge of the Art of Anaesthesia," has been strictly adhered 
to in this, the second edition. A long chapter dealing with 
anaesthesia on the western battle front was carefully pre- 
pared and discarded as too comprehensive and transient 
for inclusion in a book reserved for fundamentals. 

Repeated lectures to army officers and other medical 
men since the appearance of the first edition has served to 
crystallize the ideas of inhalation and insufflation anaes- 
thesia. The former method has been developed with a 
view to the needs of the medical man who must improvise 
his apparatus, the worker in the field hospital, casualty 
clearing station and autochir, the latter is recommended 
for the officer at work in the fully equipped base hospital. 

A chapter on the choice of the anaesthetic and the 
method of administration has been added as a resume of 
the preceding chapters. 

It would appear that there is little difference whether 
the patient to be anaesthetized receives his injuries in a 
street car accident or in a spad ten thousand feet in the 
air. Military anaesthesia resembles anaesthesia in civil 
practice with the following exceptions — the patient is not 
prepared for operation; induction must be rapid and re- 
covery must follow quickly; a large number of cases 
require treatment at one time, and, finally, the anaesthetic 

ix 



x PREFACE TO THE SECOND EDITION 

is often administered under trying conditions with impro- 
vised apparatus. If these difficulties are recognized and 
met, the well-trained anaesthetist in civil life will not fail 
to render his country a great service when called to the 
battle line. 

Many anaesthetics are now being administered by 
nurses, noncommissioned officers, and other lay persons. 
In employing such an administrator the surgeon auto- 
matically assumes the duties of the anaesthetist. He must 
make the preliminary examination, order suitable medica- 
tion as well as ante- and postoperative treatment. The lay 
administrator of anaesthetics is a technician — an anaesthetic 
technician, pure and simple. She is a technician in the 
same sense as is the lay worker in the pathological labora- 
tory who examines urine, blood, or sputum. And she holds 
the same position as does the X-ray technician who can take 
pictures but who is never expected to make a diagnosis or 
suggest treatment. When we become familiar witK the 
term anaesthetic technician and realize the legitimate limita- 
tions of such a worker we will accept these services under 
the proper supervision and control and the discussion of 
the relative merits of the medical and nonmedical anaesthet- 
ists will cease. 

The author wishes to take this opportunity to express 

his warmest appreciation for the kindly reception which 
greeted the appearance of the first edition. 

P. J. F. 

400 West 160th Street 
New York City 



PREFACE TO THE FIRST EDITION 

The proper administration of an anaesthetic is more 
than a mere mechanical performance, it is an art. 

The Art of Ancesthesia is acquired by becoming famil- 
iar with the laws which govern its administration and by 
developing the ability to properly correlate and apply these 
laws. 

It will be perceived that while a knowledge of laws is 
essential, yet this knowledge is superseded by the ability 
to properly apply them. This controlling element is what 
constitutes the essence of the art. Experience begets dex- 
terity, tact and skill. These qualities, while somewhat 
intangible, are nevertheless indispensable. They imply a 
correct and spontaneous response to the demands of the 
patient. 

The Art of Ancesthesia is not contained within any 
particular mode of administration. So-called empirical, 
percentage and shock-absorbing methods have their place, 
but should not be permitted to dominate over the art in its 
broader sense. They are its tools and must be observed 
from a point of view which considers the surgeon, the pa- 
tient, the time, the place and many other factors. 

Since familiarity breeds contempt, the anaesthetist must 
never forget to approach each case with a certain degree of 
courtesy and respect, for the possibilities of success as well 
as of failure in each are almost unlimited. 

A thousand anaesthesias, instead of leading to crude- 
ness, should make one a thousand times more careful. As 
one proceeds, one should try to formulate laws, and these 
one should strive to prove by the next case. 

xi 



xii PREFACE TO THE FIRST EDITION 

The Art of Anaesthesia implies an intimate knowledge 
of general medicine, pathology, surgery, therapeutics, psy- 
chology and special branches. Those who are not familiar 
with these subjects cannot understand the language of 
anaesthesia. 

For example, how can a lay person intelligently form 
an opinion upon such vital matters as acidosis, toxaemia, 
carbon dioxide, stimulation, and depression? How can he 
unravel and relieve the untoward symptoms which might 
arise in a case complicated by respiratory obstruction, mor- 
phine depression, and reflex inhibition? 

Death, due to anaesthesia, is not an unheard-of thing in 
lay conversation. As a consequence some timidity exists 
towards the taking of an anaesthetic. Intelligent people 

often ask : " How does Dr. know that I can safely 

take an anaesthetic? " This fairly common query implies 
not only the necessity of a preliminary examination, but of 
an examination by a physician. Aside from this consid- 
eration, a surgeon can ill afford to let the public know that 
he is willing to risk the patient's life at the hands of an 
anaesthetist who is not a medical man. Does not this very 
evident lack of concern imply to the mind of the thought- 
ful patient a greater lack of care which may include the 
operative procedure? 

A layman who administers an anaesthetic is like a blind 
guide who is led by the patient, instead of leading him. 
Unable to properly anticipate the stages of an operation 
he cannot judge the indications for artificial stimulation. 

Those who relegate anaesthesia to the layman, place 
the responsibility of the outcome on their own shoulders. 

To give an anaesthetic is one thing, to practice the Art 
of Ancethesia is another. 






PREFACE TO THE FIRST EDITION xiii 

This book, therefore, is intended as a groundwork, upon 
which the student, interne, and general practitioner may 
acquire a more comprehensive knowledge of the Art of 
Ancesthesia. Without an understanding of the broad 
truths which underlie present day anesthetization, clinical 
experiences and reference reading will lose much of their 
value. 

It is proposed to describe anesthesia as the student will 
actually find it. 

The history of ancesthesia has been briefly considered. 
A resume of the entire field of anesthesia is then attempted 
by defining and describing general, local and mixed anes- 
thesia. General ancesthesia is then taken up in detail. A 
classification of the stages of anesthesia based upon cir- 
cumstances present in all methods and by all anesthetics 
is much to be desired. It has been found in practice that 
a classification made up of the stages of induction, main- 
tenance and recovery meets these requirements admirably. 
Such a classification is easily demonstrated and grasped. 
At the conclusion of an elaboration of these stages we have 
appended a summary, which will be found valuable for 
reviewing and quizzing purposes. 

The classification of the stages of anaesthesia forms a 
basis upon which we may intelligently attack the problem 
of the signs of anesthesia. Ether being the most widely 
used anesthetic, we have thought it wise to use this type 
of anesthesia as a basis. 

The classification of the stages of anaesthesia forms a 
basis upon which to consider the administration of ether 
ancesthesia. The various methods employed, oral insuf- 
flation, intrapharyngeal insufflation, intratracheal insuffla- 
tion, rectal and intravenous methods are fully discussed. 



xiv PREFACE TO THE FIRST EDITION 

General ancesthesia by ethyl chloride, chloroform, ni- 
trous oxide, nitrous oxide and oxygen, and nitrous oxide 
oxygen ether are then taken up, the stages of ancesthesia 
in each case forming a common basis for the administra- 
tion and the signs described. 

In accordance with the resume suggested above, local 
anaesthesia is then discussed. A chapter on mixed or spinal 
anaesthesia follows. ' 

Medication preliminary to ancesthesia is next taken up. 
This is followed by a chapter on carbon dioxide and re- 
breathing. Bearing in mind the needs of the general 
practitioner, a chapter on emergency ancesthesia has been 
prepared. Last, but not least, we recommend the patient's 
point of view to the earnest anaesthetist. 

The collection of table positions which are presented in 
connection with the classification of the stages of anaesthe- 
sia is, it is believed, quite complete. 

Chapters I, II, III, IV, XIII, XIV, XVIII and 
XX have been written with the needs of the trained nurse 
in mind. 

In conclusion the author wishes to take this oppor- 
tunity to thank Dr. G. W. Crile for the hospitality ex- 
tended him while in Cleveland, during which visit he was 
enabled to study the method of anoci association, so earn- 
estly and constantly advocated by his charming host. He 
is also indebted to Dr. John B. Murphy for courtesies 
extended while visiting his clinic in Chicago, and is under 
deep obligations to Dr. Charles Mayo for a delightful visit 
to his remarkable clinic; to the gentlemen of the American 
Surgical Society indebtedness is expressed for many privi- 
leges extended while visiting in the West. 

To Dr. C. N. Dowd the author is indebted, hot only 



PREFACE TO THE FIRST EDITION xv 

for innumerable courtesies, but for the help which he has 
offered in curtailing crudeness in this book ; to Dr. Lucius 
Hotchkiss for having made much of this book possible ; to 
Dr. Karl Connell for having explained the use of the 
Ansesthetometer, and for the loan of original illustrations ; 
to Dr. L. Booth for illustrations on intratracheal insuffla- 
tion. To the Attending Staff of Fordham Hospital 
and to the Faculty of Fordham University Medical 
School indebtedness is acknowledged for much encourage- 
ment and support, as well as to the Attending Staff of the 
Woman's Hospital, with whom many pleasant hours have 
been passed. 

Acknowledgment is made to Dr. K. Dwight for assis- 
tance in the classification of the stages of anaesthesia. To 
Berchman Bittl, O. M. Cap., and an old friend Robert 
Getty for reading the proofs. To Dr. A. Bruno for assis- 
tance in preparing many of the illustrations. To Dr. L. 
De Yoe for preparing the index. To the daughters of 
the late Dr. C. W. Long, the discoverer of ether anaes- 
thesia, grateful acknowledgment is made for photographs 
and pamphlets relating to the discovery of ether anaesthesia. 

For the loan of illustrations credit is due Appleton 
& Co.. The Modern Hospital Magazine, The Journal of 
the American Medical Association and Old Penn. 

Finally to J. B. Lippincott Co. gratitude is expressed 
for the patience and courtesy which they have shown in 
the preparation of this book. 

P. J. F. 
120 Central Park South, 
New York City. 



CONTENTS 



PAGE 

Introduction (History) 1 

PART I 

Bearing Upon the Classification of Anaesthesia, Its Characteristic Signs 
and Its Administration by the Various Methods Ordinarily Employed 

Types of Anaesthesia 

A. GENERAL ANAESTHESIA. B. LOCAL ANAESTHESIA. C. SPINAL ANaESTHESIA. 

A. GENERAL ANaESTHESIA 
CHAPTER 

I. General Anaesthesia 11 

1. Complete. 2. Incomplete. 

II. General Anaesthesia. A Detailed Consideration 15 

1. Induction. 2. Maintenance. 3. Recovery. 

III. Signs of Anaesthesia 82 

1. Respiration. 2. Color. 3. Muscle. 4. Eye. 5. Pulse. 

IV. Ether Anaesthesia. General Considerations 120 

1. Oral Insufflation. 2. Intrapharyngeal. 3. Intratracheal. 4. Oil 
Ether Rectal. 5. Intravenous. 

V. Ethyl Chloride 181 

General Consideration. Technic of Administration. 

VI. Chloroform 185 

General Consideration. Technic of Administration. 

VII. Nitrous Oxide 201 

General Consideration. Technic of Administration. 

VIII. Nitrous Oxide Oxygen Anaesthesia 214 

General Consideration. Technic of Administration. 

IX. Nitrous Oxide Oxygen Ether Anaesthesia 223 

General Consideration. Technic of Administration. Anoci Asso- 
ciation. 

B. LOCAL ANaESTHESIA 

X. Unusual Methods 249 

1. By Freezing. 2. By Pressure. 3. By Regional Intravenous Injec- 
tions of Novocaine. 

XI. Usual Methods 255 

1. By Surface Amplication. 2. By Infiltration Anaesthesia. 3. By 
Conductive Anaesthesia. 

C. SPINAL ANaESTHESIA 

XII. General Consideration 261 

XIII. Method of Administration 265 



xvu 



xviii CONTENTS 

PART II 

Bearing Upon Factors Incidental to the Actual Administration of the 

Anesthetic 
chapter page 

XIV. Preliminary Medication in Anesthesia 277 

XV. Post-Operative Treatment of the Patient; Duties of the Nurse 

Before, During and After Anesthesia 285 

XVI. Carbon Dioxide and Rebreathing 296 

XVII. Emergency Anesthesia 308 

XVIII. The Anesthetist's Records 318 

XIX. Aspirators 321 

XX. The Point of View of the Patient 328 

XXI. Selection of Anesthetic and Method of Administration 334 

Appendix 361 

Bibliography , 365 

Index 367 



ILLUSTRATIONS 



FIG. PAGE 

The Actual Effect of Oxygen upon the Color of Human Blood, Forming the 
Basis for the Author's Haemoxometer Frontispiece 

1. Homer 3 

2. Du Bartas , 3 

3. Shakespeare . . 3 

4. Dr. C. W. Long 3 

5. A Documentary Reference to the Existence of Ether Frolics 4 

6. The First Suggestion of the Use of Ether as an Anaesthetic 4 

7. An Account of the First Anaesthesia 4 

8. Long's Discovery no Secret 5 

9. Curve of Complete Anaesthesia 12 

10. Curve of an Incomplete Anaesthesia 13 

11. Correct Control of the Head, the Patient Across the Bed 24 

12. Incorrect Control of the Head, the Patient Parallel with the Bed 24 

13. The Boxwood Mouth Wedge 34 

14. The Author's Modification of the Connell Throat Tube 34 

15. Throat Tube in Place 35 

16. Table in Trendelenburg Position 38 

17. Patient Ready for Trendelenburg Position 38 

18. Patient in Trendelenburg Position 39 

19. Table in Position for Trendelenburg Position — Feet Straight 39 

20. Patient in Trendelenburg Position — Feet Straight 41 

21. The Simms Position 41 

22. Position Favoring Brachial Paralysis 13 

23. Position Favoring Musculospiral Paralysis 43 

24. Position for Exploration of Knee-joint 44 

25. Prone Position 44 

26. Prone Position for Sacral Operation 45 

27. Position for Operation on Sacrum 45 

28. Table with Gall-bladder Kidney Rack in Position 46 

29. Patient in Kidney Position Over Rack 46 

30. Patient in Gail-Bladder Position Over Rack 49 

31. Table Broken Instead of Raising Rack 49 

32. Kidney Position on Broken Table 50 

33. Gall-bladder Position on Broken Table 50 

34. Ordinary Neck Position for Goitre Operation 51 

35. Ordinary Neck Position for Glands of Neck 51 

36. The Rose Position 52 

37. The Elevated Neck Position 52 

38. The Table Set for Elevated Neck Position 53 

xix 



xx ILLUSTRATIONS 

39. Patient in Elevated Neck Position 53 

40. Table Set for Lithotomy 55 

41. Patient in Lithotomy • • • 55 

42. Table Set for Closure of Upper Abdominal Wounds 56 

43. Patient in Position for Closure of Upper Abdominal Wounds 56 

44. The Walcher Position • • 57 

45. Diagram to Explain the Walcher Position 58 

46. Curve Showing Variable and Constant Maintenance 61 

47. Diagram Showing Vapor Tension of Ether in Alveolar Air During the Three 

Stages of a Complete Anaesthesia 65 

48. Vapor Pressure of Ether in Tidal Air for Induction and Maintenance of 

Full Anaesthesia 6H 

49. Plot of Ether Vapor Pressure in Pulmonary Tidal Air 69 

50. Plot of Ether Tension in Body 70 

51. Zones of Ether Anaesthesia 73 

52. Recovery by Crisis 76 

53. Recovery by Lysis 77 

54. Gauze on Upper Lip Moistened with Essence of Orange 80 

55. 56. Sylvester Method— Artificial Respiration 93, 91 

57. Simple Form of Mercury Manometer ,, 95 

58. The Hsemoxometer 96 

59. Normal Movements of Diaphragm 104 

60. Movement of Diaphragm Before a Fatal Issue 104 

61. Diagram Showing Enervation of the Dilator and Sphincter Pupilse 109 

62. 63. Intravenous Administration of Saline 115, 116 

64. Hypodermoclysis 118 

65. Yankauer Gwathmey Drop and Vapor Mask 123 

66. Making the Ether Drop Bottle 124 

67-71. Ether by the Semi-open Drop Method 128 

72. The Author's Apparatus for the Administration of Ether by the Closed Drop 

Method and for Gas Oxygen Ether Anaesthesia 132 

73, 74. Bennett Apparatus 137 

75. Apparatus for the Vapor Method of Oral Inhalation 144 

76. Showing Pharyngeal Tube and Nasal Tube Employed for Intrapharyngeal 

Inhalation. The Stylet is for Intratracheal Use 147 

77. The Author's "Tin Can" Method 148 

78. Intrapharyngeal Inhalation with Rebreathing, Nasal Method 154 

79. Intrapharyngeal Inhalation with Rebreathing, Oral Method 154 

80. Jackson Laryngoscope with Tieman Pocket Flashlight Adapter 154 

81. Showing Oral Tube, Special Mouth Gag, and Simplified Chloroform Apparatus 155 

82. Ansesthetometer (Connell) 154 

83. Nasal Tubes 155 

84. Nasal Tube in Place 155 



ILLUSTRATIONS xxi 

85, 86. Intrapharyngeal Anaesthesia 155 

87. Electric Motor Blower and Suction Apparatus with Ether Attachment 161 

88. Intratracheal Catheter 162 

89. Jackson Laryngoscope and Rheostat 163 

90. 91. Intratracheal Anaesthesia 165-166 

92. Intravenous Apparatus 177 

93. Chloroform Containers 182 

94. Ethyl Chloride Container, Spray Type 182 

95. Various Sizes of Gas and Oxygen Tanks 202 

96. Reducing Valve 203 

97. Label on N2O Cylinder 204 

98. Plan of Apparatus Installed in Lakeside Hospital for the Manufacture 

of Nitrous Oxide 205 

99. The Author's Cylinder Holder 209 

100. The Author's Cylinder Holder Clamped to the Edge of a Table 210 

101. Cylinders Lying on a Chair Supported by the Author's Holder 211 

102. Cylinder Clamp Fastened to a Window-sill 212 

103. A Simple Wooden Stand for Three Cylinders, Suitable for Hospital Use. ... 215 

104. Miller Apparatus 230 

105. McKesson Apparatus 231 

106. The Gwathmey Gas Oxygen Apparatus 231 

107. Connell Gas Oxygen Apparatus 232 

108. Zones of Nitrous Oxide Oxygen Anaesthesia in Normal Man without Sup- 

plemental Narcosis 234 

109. Connell Nitrous Oxide, Oxygen, Ether Flow Control 235 

110. Esmarch Bandage 251 

111. 112. Bandage for Regional Intravenous 253 

113. Dunn Automatic Outfit for Local Anaesthesia 257 

114. Relative Sensitiveness of Tissues 259 

115. The Relations of the Lumbar and Dorsal Interspaces to the Crests of the 

Ilia and Lower Ribs 266 

116. Localization of the Spinal Interspaces 267 

117. The Point of Skin Puncture is Anaesthetized by Freezing 269 

118. The Needle is Introduced in the Middle Line Forward and Inward 270 

119. As the Dura is Pierced, the Cerebrospinal Fluid Escapes and May be Col- 

lected in Test-tube for Further Study 271 

120. The Syringe Containing the Proper Dose of Stovaine is Attached to the 

Needle and Slowly Injected 272 

121. Nurse Grasping Patient's Wrists 286 

122. The Fowler Position 292 

123. The Shock Position 293 

124. Tracing of Experiment in Respiration 306 

125. Making the Cone 313 

126. Tin-can Method for Nirta Pharyngeal Anaesthesia 315 

127. Funnel with Tube for Intratracheal Anaesthesia 316 



xxii ILLUSTRATIONS 

128. Front of Anaesthesia Record Card . . .-, 318 

129. Reverse of Anaesthesia Record Card 319 

130. Foot Aspirator .322 

131. Water Aspirator 323 

132. Electrical Aspirator . 324 

133. Ejector for Steam Aspirator 324 

134. The Steam Pump Aspirator Complete with Aspirating Tongue Depressor. . . 325 

135. Aspirating Tongue Depressor 326 



, 



THE ART OF ANAESTHESIA 

INTRODUCTION 

THE HISTORY OF ANESTHESIA 

The history of anaesthesia may be broadly divided into 
two periods : the pre-ancesthetic period and the ancesthetic 
period. The pre-ancesthetic period ends and the ancesthetic 
period begins with the discovery of ether in 1842 and its 
general introduction in 1846. 

THE PRE-ANCESTHETIC PERIOD 
(Before 1842) 

The beginning of the use of anaesthesia is not known ; it 
dates from the earliest antiquity. The following com- 
monly accepted references prove that narcotics were used 
in pre-ancesthetic times. 

Homer (Fig. 1), in "The Odyssey," says: "Helen 
dropped into the wine of which (the soldiers) drank a 
drug, an antidote of grief and pain inducing oblivion to all 
ills. He who drinks of this mingled cup sheds not a tear 
the livelong day were death to seize his venerated sire or her 
who gave him birth, or were the sword buried in the bosom 
of his brother or greatly loved sister, no tear would even 
then bedew his cheeks." 

In 484 B.C., Herodotus refers to the inhalation of the 
vapors of hemp (Cannabis Indica) to produce intoxication. 

In 23 a.d., Pliny, the Roman author, speaks of the juice 
of certain leaves taken before cuttings and burning to pro- 
duce sleep. 



St ANAESTHESIA 

In 134 a.d., Galen, the physician, speaks of the power 
of mandr agora to paralyze sensation and motion. 

In 250 a.d., Lucian, the Greek historian, refers to the 
narcotic effects of mandragora. 

In 1250, Hugo de Luca, physician, refers to a certain 
oil with which he put patients to sleep before operations. 

In 1544 Du Bartas implies a custom by writing: 

Even as a Surgeon, minding off to cut 
Some cureless limb, before in use he put 
His violent engines on the viscious member 
Bringeth his patient in a senseless slumber. 

In 1613, Shakespeare (Fig. 3) in " Cymbeline," Act I, 
Scene VI, implies the use of a narcotic. (Cornelius plans 
to give a secret drug which) 

Will stupify and dull the sense awhile, 

No danger in what show of death it makes. 

In 1772, Priestly discovers nitrous oxide. 

In 1804, Sir Humphrey Davy suggests the use of ni- 
trous oxide as an anaesthetic. 

In 1818, Faraday notes resemblance between nitrous 
oxide and ether. 

The narcotic effects secured in ancient, mediaeval and 
modern times, during the period which we have designated 
as pre-ancesthetic (previous to 1842), were brought about 
chiefly by the use of: 

Mandragora root (related to belladonna). 

Cannabis indica, a certain kind of hemp, smoked as 
haschisch. 

Secret Chinese mixtures. 

Pressure on blood-vessels and nerve trunks. 

Hypnotism. 

The ancesthetic period was foreshadowed by the spora- 
dic use of nitrous oxide both in England and America. At 
about this time it became a common practice for persons to 



INTRODUCTION 





Fig. 1. — Homer. 



Fig. 2.— DuBartas. 





Fig. 3. —Shakespeare. 



Fig. 4.— Dr. C. W. Long, from a crayon 

drawing made in 1842. 

(Courtesy of Florence Long Bartow.) 



Homer, Du Bartas and Shakespeare, Poets of the pre-anaesthetic period who wrote of the use of narcotics 

for the control of pain. Dr. C. W. Long, of Georgia, who opened the anaesthetic period by employing 

ether, to secure unconsciousness during an operation which he performed in the spring of 1842. 



4 ANAESTHESIA 

inhale the fumes of ether for the exhilarating effects. This 
practice sometimes formed the chief entertainment at coun- 
try parties. These ether frolics probably suggested the use 
of this agent as an anaesthetic, for during these frolics, the 
stage of excitement occasionally led to unconsciousness and 
loss of sensation. A portion of a document, sworn to by 
one R. H. Goodman of Georgia, shown in Fig. 5, " refers 
to these ether frolics." 

THE ANESTHETIC PERIOD 
(From 1842 to the present time) 

The proper discovery of anaesthesia involves the names 
of four investigators: Crawford W. Long of Georgia; 
William T. Morton of Hartford; Horace Wells of Hart- 
ford and Charles T. Jackson of Boston. 

Dr. Crawford Long (Fig. 4) of Georgia, having ob- 
served the loss of sensation incidental to injuries received 
during ether frolics, concluded that sulphuric ether might 
well be used to allay the pain of surgical operations. This 
idea occurred to Dr. Long late in the year 1841, as may be 
seen in Fig. 6. In the spring of 1842 Dr. Long put his 
theory into practice. After having rendered his patient, 
one James Venable, unconscious with inhalations of ether, 
he successfully removed two small tumors from the man's 
neck. The documents reproduced in Figs. 6 and 7 give 
brief accounts of the first operation ever done under ether. 

H. Wells of Hartford had a tooth extracted under the 
influence of nitrous oxide. He subsequently used it upon 
his patients with such good results that he attempted a 
demonstration at the Harvard University Medical School. 
His exhibition was a failure and so disheartened him that 
he later committed suicide. , 

W. T. Morton was a student under Wells and conse- 




Courtesy Dr. Allen J. Smith, Old Penn. 

Fig. 5. — Ether frolic. A documentary reference to the existence of Ether Frolics. 









«h v #^ 






~x 









v<s> 









" ^ ? /---; ; ^6 y ^-- *%.-• 



A--' tTptM^icJkff 



iCourtesy Dr. Allen T. Smith, Old Penn. ,. t;/1 

Fig. 6 — The first suggestion of the use of ether as an anaesthetic. 






£y £^lS&i~&^gt^<L-^ C*£& %^£&1€AjC/ % 4S /Z4JUZC0 



Courtesy Dr. Allen J. Smith. Old Penn. 

Fig. 7.— An account of the first anaesthesia. 




<!>» 



4-igv4'^ ^ 



INTRODUCTION 5 

quently was familiar with the use of nitrous oxide. While 
serving as a medical student under the preceptorship of 
C. T. Jackson, the latter suggested that he use ether in 
place of nitrous oxide. Morton did so and after several 
experimental successes gave a demonstration at the Massa- 
chusetts General Hospital, October 16, 1846. 

As the operator, Dr. Warren, remarked at the conclu- 
sion of the operation, " Gentlemen, this is no humbug," so 
subsequent events proved this public demonstration to be 
the birth of a new era. The crudeness of pre-ansesthetic 
methods is vividly depicted by Hayden, who describes an 
operation performed on a woman: " With a meek, implor- 
ing look and the air of a startled fawn, as her modest gaze 
meets the bold eyes fixed upon her, she is brought into the 
amphitheatre crowded with men, anxious to see the shed- 
ding of her blood, and laid upon the table. With a knowl- 
edge and merciful regard as to the intensity of the agony 
which she is to suffer, opiates and stimulants have been 
freely given her which, perhaps at this last stage, are again 
repeated. She is cheered by kind words and the informa- 
tion that it will soon be over and she freed forever from 
what now afflicts her ; she is enj oined to be calm and to keep 
quiet and still; and with assistance at hand to hold her 
struggling form, the operation is commenced. 

"But of what avail are all her attempts at fortitude! At 
the first clear, crisp cut of the scalpel, agonizing screams 
burst from her, and with convulsive efforts she endeavors 
to leap from the table; but force is nigh. Strong men 
throw themselves upon her and pinion her limbs. Shrieks 
upon shrieks make their horrible way into the stillness of 
the room, until the heart of the boldest sinks into his bosom 
like a lump of lead. 

" At length it is finished and, prostrate with pain, weak 



6 ANAESTHESIA 

from her exertions and bruised by the violence used, she 
is borne from the amphitheatre to her bed in the wards, to 
recover from the shock by slow degrees." 

A short time after this demonstration at the Massachu- 
setts General Hospital, Morton and Jackson patented 
ether and called it letheon. The secret soon leaked out, 
however, because of the characteristic odor of the new prep- 
aration. Petition was later made before Congress for 
recognition. The honorarium consisted of one hundred 
thousand dollars. Morton, Jackson and a friend of Wells, 
who had since died, became claimants. As the controversy 
was about to close, Jackson recognized the claims of Long, 
which had just been received. The bill was thereupon 
dropped and never again presented. 

In recalling the facts pertaining to the discovery of 
ether we should remember that Dr. Crawford Long of 
Georgia was the first to use ether as an anaesthetic. He 
made no secret of his discovery, as is seen in Fig. 8, but 
his comparative isolation and the fact that he had no large 
institutional backing prevented his discovery from becom- 
ing widely known. Four years later the use of ether as an 
anaesthetic became universal through the sanction which its 
employment received at the Massachusetts General Hos- 
pital, where it had been introduced by Morton and Jackson. 
In the following year, 1847, chloroform was introduced 
into England by Sir J. Y. Simpson. The employment of 
nitrous oxide as an anaesthesia by H. Wells, in 1844, fore- 
shadowed the use of nitrous oxide and oxygen by 
E. Andrews, of Chicago, in 1868. In 1844 Koller, of 
Vienna, introduced cocaine. Ethyl chloride, although 
recognized as an anaesthetic in 1847, did not become widely 
used until about 1900. About five years later H. Braun 
suggested employment of novocaine as local anaesthetic. 



PART I 

BEARING UPON THE CLASSIFICATION OF 
ANAESTHESIA, ITS CHARACTERISTIC SIGNS 
AND ITS ADMINISTRATION BY THE VARIOUS 
METHODS AND AGENTS ORDINARILY EMPLOYED 



PART I 

ANESTHESIA— ITS THREE TYPES 

All anaesthesia is included in one of three types accord- 
ing to the anatomical division of the nervous system 
involved: A, general anaesthesia; B, local anaesthesia; C, 
spinal anaesthesia, 

Gexeral Ax^esthesia is that type of anaesthesia in 
which the central nervous system, consisting of the brain 
and spinal cord, and the peripheral nervous system, consist- 
ing of afferent nerves, efferent nerves and tactile end 
organs, are brought under the influence of the anaesthetic. 

Local Ax^esthesia is that type of anaesthesia in which 
only the peripheral nervous system is brought under the 
influence of the anaesthetic. 

Spinal Ax.esthesia is that type of anaesthesia in which 
the spinal cord and the peripheral nerves are brought under 
the influence of the anaesthetic. 

GENERAL ANESTHESIA 

In order to produce general anaesthesia, it is necessary 
that the anaesthetizing substance enter into the general 
circulation. Through this medium only can the higher 
centres be brought under control. 

General anaesthesia may be brought about indirectly 
as follows: 

(1) by oral, pharyngeal and intratracheal inhalation 
and insufflation; (2) by administering the drug per rectum. 
Directly as follows : by intravenous anaesthesia. 

LOCAL ANESTHESIA 
Local anaesthesia is the anaesthetization of the end 
organs or nerve trunks, and may be produced by the fol- 



10 



ANAESTHESIA 



lowing means: (1) by freezing the part; (2) by pressure 
on the nerve trunks or by pressure producing ischemia of 
the part; (3) by regional intravenous injections of novo- 
caine; (4) by the injection of novocaine or some other drug 
into the skin or deeper tissues. 



SPINAL ANiESTHESIA 
Spinal ancesthesia is the anesthetization of the spinal 
cord and nerve trunks. This may be brought about by in- 
j ections of novocaine, tropacocaine or some other drug into 
the spinal canal. 



CHAPTER I 

A. GENERAL ANAESTHESIA THE FIRST AND MOST 
IMPORTANT TYPE OF ANESTHESIA 

There are two classes or degrees of general ancesthesia: 
complete and incomplete. 

COMPLETE ANESTHESIA 

Let us first identify complete ancesthesia. With the 
clear understanding of this class, there will be no difficulty 
in understanding incomplete ancesthesia. 

Complete ancesthesia is divided into three distinct 
stages : 

(a) The stage of induction. 

(b) The stage of maintenance. 

( c ) The stage of recovery. 

The stage of induction is further divided into three 
periods. 

(a) The period of excitement, cerebral and mus- 
cular. 

(b) The period of rigidity. 

(c) The period of relaxation. 

The stage of maintenance is not subdivided. 
The stage of recovery is further divided into two 
periods : 

(a) The return of the reflexes. 

( b ) The return of consciousness. 

The stage of induction extends from the beginning of 
the administration of the anaesthetic to the point where 
general muscular relaxation has been brought about. This 
stage, leading the patient as it does from consciousness to 
deep anaesthesia, is the most difficult and important of the 

11 



12 



ANAESTHESIA 



three stages. The undervaluation of this importance is 
responsible for the failures which one sees in otherwise un- 
complicated anaesthesias. To completely induce anaesthesia 
takes from six to eight minutes. The correct control of 
this stage seriously affects the stage of maintenance, which 
is to follow. 

The stage of maintenance extends from the completion 
of relaxation to the point where the anaesthetic level, which 
has been carried, is permitted to drop, with a view of allow- 
ing the patient to recover. 



RELAXATION 



RlOlOlTr 



RETURN Or 
REFLEXES 



INCITEMENT 




RETURN OF 
CONSCIOUSNESS 



Fig. 9.— Curve of a complete anaesthesia. 

The stage of maintenance should begin just before the 
time of the first incision and should cease shortly before 
the conclusion of the operative procedure. In maintaining 
anaesthesia, our problem is to supply to the patient the 
ether which he loses through his respiration, exposed capil- 
lary surfaces, through the destruction of the ether radical, 
etc., after anaesthesia has been properly brought about. 
While strictly speaking there are no periods of mainte- 
nance, yet there are levels of lightness and depth where 
certain reflexes may be retained or abolished. 

The stage of recovery is the inverse of the stage of 
induction. 



GENERAL ANAESTHESIA 



13 



The stage of recovery begins when the constant level, 
which has been carried during the stage of maintenance, is 
permitted to permanently drop with a view of stopping the 
administration altogether. The stage of recovery ends 
with the return of consciousness. 

Our problem in this stage is when to permit its appear- 
ance and how best to hasten its onset and completion. 

Induction anaesthetizes the patient. 

Maintenance keeps him anaesthetized. 

Recovery returns him to consciousness. 

These stages forming a complete anaesthesia may be 
represented as shown graphically in Fig. 9. 

INCOMPLETE ANESTHESIA 
The term incomplete or partial anesthesia may be ap- 
plied to a large number of anaesthesias induced for opera- 



RELAXATION < 
(partial or absent) / 






RIGIDITY •// 


VS, RETURN OF 
VT REFLEXES 


EXCITEMENT , 






RETURN OF 
CONSCIOUSNESS 


»»- 


to 

— » 

MIN. 


15 

** — — 

MIN. 


• ->■ 



Fig. 10. — Curve of an incomplete anaesthesia. 



tions, which do not require complete relaxation, and which 
may be accomplished in a short period of time. The open- 
ing and curetting of an abscess, or the dressing of a wound 
may be done with perfect satisfaction to surgeon, patient 
and anaesthetist in the presence of an incomplete anaesthesia. 



14 ANAESTHESIA 

In an incomplete anaesthesia there is no stage of main- 
tenance. This stage, it will be remembered, does not ap- 
pear until general relaxation obtains. Strictly speaking, 
one cannot expect the patient to pass from consciousness 
to the period of excitement or rigidity and then continue 
along an even plane at the convenience of the anaesthetist. 
The patient will either become light and vomit, or will pass 
more deeply under the influence of the anaesthetic and be- 
come relaxed. 

The curve of an incomplete ancesthesia may be repre- 
sented as shown in Fig. 10. 

Before starting the anaesthesia, the anaesthetist should 
decide the question — Does this patient require complete or 
incomplete ancesthesia? 



CHAPTER II 

THE DETAILED CONSIDERATION OF A COMPLETE 
GENERAL ANAESTHESIA 

Complete general anaesthesia is conveniently divided 
into three stages : induction, maintenance and recovery. 

The stage of induction is further subdivided into three 
periods : excitement, rigidity and relaxation. 

I. INDUCTION 

THE PERIOD OF EXCITEMENT 

We shall now take up in detail the first period, that 
of excitement, touching upon its evidences, causes and 
control. 

A. The Evidences of the Period or Excitement. — 
Excitement shows itself in an anxious expression, unusu- 
ally rapid pulse, irregular sighing respirations, licking of 
the lips, a constant clearing of the throat or fidgety move- 
ments of the hands and feet. 

A woman sometimes complains of the odor of the anaes- 
thetic in the room or that the face piece is uncomfortable. 
She holds her breath after the first whiff of the anaesthetic. 
This is often followed by shallow breathing and movements 
of the head from side to side. Later, she may talk, laugh 
or scream. Following a period of fairly satisfactory 
breathing, she may suddenly begin to struggle violently, 
tearing off the mask, flexing her thighs on her abdomen 
and rolling off the table if not restrained. In a man the 
muscular movements frequently begin slowly but with 
great strength, requiring the combined assistance of those 

15 



16 ANAESTHESIA 

present to restrain him. Jactitation or convulsive move- 
ments of the arms or legs, grinding of the teeth and expec- 
toration into the face piece are not uncommon. In chil- 
dren, bladder movements are of frequent occurrence. 

B. The Causes of the Period of Excitement. — 
Over-concentration of the anaesthetic ; lack of any prepara- 
tion or faulty preparation; temperament; alcoholism; ex- 
cessive smoking; sexual; remarks which the patient hears 
before losing consciousness; physiological effects of the 
ether ; failure to understand what anaesthesia means ; nasal 
obstruction; moving patients while in the early stages of 
induction ; excessive fear, especially in children, and previ- 
ous unsatisfactory anaesthesia, are all causes of excitement. 

We must differentiate excitement per se and the sud- 
den determination on the part of the patient to have the 
operation postponed. 

If the patient is rational and has not received any of the 
anaesthetic, she must never be forcibly anaesthetized. Such 
a procedure may give grounds for a suit. In this connec- 
tion it must be said that the patient should never be anaes- 
thetized without the presence of one or more witnesses. 

C. The Control of the Period of Excitement. — 
Excitement is controlled by applying indirect and direct 
means. 

The Indirect Control of the Period of 'Excitement. — 
(a) The routine preliminary visit; (b) preliminary diet 
and medication. 

The Routine Preliminary Visit. — The preliminary visit 
should be made for two reasons: first, for the purpose of 
physical examination ; second, for the purpose of applying 
suggestive therapeutics. 

In making the physical examination there are at least 
five points which should be covered. 



COMPLETE GENERAL ANAESTHESIA 17 

1. Anaesthetic history: Was the patient ever anaesthe- 
tized before? Was the course of anaesthesia smooth or 
stormy, and was there much after-sickness? 

2. Has a urine examination been made ? If so, is there 
sugar, acetone or albumen present? 

3. Listen to the chest ; rule out or determine the pres- 
ence of tuberculosis, bronchitis or asthma. 

4. Examine heart. Note whether there be heaving 
apex impulse, tachycardia, irregularity in rhythm or mur- 
murs. Note color of lips and circulation beneath the fin- 
ger-nails. The patient should be asked to hold the breath 
as long as possible in the manner prescribed as follows : He 
is requested to breathe deeply two or three times through 
the nose; at the end of an inspiration the nose is pinched 
by the anaesthetist and the patient is asked to hold the 
breath as long as possible. If it is impossible for him to do 
so for 40 seconds, acidosis or poor cardiac compensation 
may be suspected. 

The anaesthetist is not usually considered proficient in 
physical diagnosis. He has exceptional opportunities to 
become so, and should never miss the opportunity to do 
thorough work. 

5. Look into the mouth; first, that you may observe 
false teeth, loose teeth or chewing gum; second, that you 
may become familiar with the manner with which the teeth 
approximate, noting the best position for the insertion of 
an emergency mouth prop or gag. 

Suggestive therapeutics are invaluable. 

The patient is concerned for her safety. She wishes 
you to assure her that her heart is " perfect/' that she will 
safely pass through the anaesthesia. Your questions and 
physical examinations will in themselves comfort her, and 

2 



18 ANESTHESIA 

you may advance your negative findings as proofs of her 
ability to take the anaesthetic. Win her confidence and you 
will have done much to control the period of excitement and 
to lessen shock. 

Preliminary Diet and Medication. — Morning opera- 
tions are more satisfactory than those done later in day. 

Suppose an operation for appendectomy to take place 
Monday morning at 9.00 a.m. At the preliminary visit, 
which may be Saturday evening, an ounce of castor oil is 
ordered to be taken at bedtime. Sunday, the usual diet 
is permitted, and in addition half a pound of some good 
candy is suggested. By supplying an excess of glucose, 
candy helps to neutralize the acidosis caused by the anaes- 
thetic. This treatment is harmless to those with normal 
digestion, and is usually most grateful to the patient. If 
she is a poor sleeper, restless and apprehensive, she should 
receive 7 gr. veronal in hot milk before retiring Sunday 
night. She should be encouraged to sleep as late as possi- 
ble Monday morning. Should she wake at 7.00, she may re- 
ceive a cup of light broth but no solid food. At 8.30, a 
hypodermic of 1/6 gr. morphine sulphate and 1/150 gr. 
atropine should be given. 

We are now confronted by the question — where shall 
we induce the anaesthesia ? It may be done in one of four 
places: (1) in the patient's bed; (2) in the anaesthetizing 
room on a stretcher; (3) on the operating table in the 
anaesthetizing room; (4) on the operating table in the 
operating room. Two considerations should influence our 
decision: (a) The patient should not be moved after the 
anaesthetic is begun; (b) the patient should be spared that 
which will cause anxiety: i.e., the sight of instruments. 
In the home the anaesthetic should invariably be induced 



COMPLETE GENERAL ANAESTHESIA 19 

upon the bed or table where the operation is to take place. 

In the hospital, the anaesthetic should be induced on the 
operating table in the anaesthetizing room. 

If this be impossible, choose the lesser evil of frighten- 
ing the patient and induce the anaesthesia in the operating 
room upon the operating table. Most patients are not 
frightened, however, if the circumstances are explained 
before hand. 

Patients, who are not moved after the anaesthetic has 
commenced, usually have a smoother induction. They may 
be scrubbed up upon the first signs of relaxation and it is 
not necessary to lift their dead weight. 

The indirect control of the period of excitement may 
therefore be summarized as follows : 

( For suggestive therapeutics. 

Preliminary visit ~j Examination : History, heart, lungs, 

\ urine and teeth. 

! General diet with candy. 
Sleep, with veronal if necessary. 
Preliminary morphine where not con- 
traindicated. 

( On operating table in anaesthetizing 

Place of anaesthesia < room. 

V.On operating table in operating room. 

The Direct Control of the Period of Excitement. — The 
direct control of the period of excitement may be described 
as that control which we exert after the patient has reached 
the place of operation. 

If the indirect control has been conscientiously carried 
out, i.e., if the patient has received a preliminary visit, the 
confidence won, a good night's rest secured and prelimi- 
nary morphine received, the period of excitement will be 
conspicuous by its absence. 



20 ANAESTHESIA 

This ideal, however, is not always obtained in private 
work and seldom in the hospital, where the anaesthetist 
often meets the patient for the first time in the anaesthetiz- 
ing room, lying on a stretcher swaddled in blankets and 
strapped to a frame. The alcoholic, the inveterate smoker, 
crying children, hysterical women, and those who fail to 
understand what anaesthesia means are placed before him 
without any effort having been made to investigate their 
various needs. The treatment of these intrinsic causes 
of excitement resolves itself into a sympathetic attitude on 
the part of the anaesthetist. He may express this by his 
manner of approach, his touch, and his tone of voice. It 
is never too late to inquire into urine analysis, false teeth, 
chewing gum, previous anaesthetization, etc. The patient 
should be instructed to hold his breath. If he cannot do so 
for a period of, at least, 30 seconds, acidosis or poor car- 
diac compensation may be suspected. The extrinsic causes 
of excitement may, however, be more directly controlled. 

The normal reflexes of the pharynx and larynx are to 
be abolished. These membranes must be rendered insen- 
sitive to any concentration of ether vapor. In the presence 
of these reflexes, the patient will not be anaesthetized. Vapor 
which is intolerable to these membranes in their normal 
state is of insufficient strength to put the patient to sleep. 

We may abolish these reflexes by coaxing or by driv- 
ing them to sleep. 

Coaxing should always be the method of choice. 

This is best accomplished by the employment of the 
drop method. If the open drop method is employed, invite 
the patient to count slowly and loudly; or if a child, to 
blow the smell away. If the patient holds the breath or 
coughs, stop until the breathing is once more regular; then 
start again and increase as rapidly as the tolerance will 



COMPLETE GENERAL ANAESTHESIA 21 

permit. The point will soon be reached where the maximum 
amount (as much as can be vaporized) is being given, itt 
is only a question of a few moments then to the completion 
of induction. 

Driving the reflexes to sleep. fr 

Some patients exhibit an abnormal degree of sensitive- 
ness to ether vapor. If it is found that even diluted vapor 
cannot be tolerated, the following must be considered : ^n 
the normal case the necessity to breathe or the " Besoin de 
respire " overcomes whatever inhibition may exist by rea- 
son of the slightly irritating effect of the ether vapor. In 
the abnormal case in question the inhibition is not overcome 
by the " Besoin de respire." Our indications are therefore: 

1. To increase the necessity for breathing. 

2. To abolish the reflexes by shocking them through the 
use of very concentrated ether vapor. 

The first is accomplished by using an air-tight appara- 
tus which limits oxygenation, and by rebreathing affords 
the stimulating C0 2 . 

The second is accomplished by having convenient means 
whereby the concentration of the ether vapor used may be 
rapidly increased. 

The patient must breathe, and in doing so quickly para- 
lyzes the membranes, thereby doing away with the cause 
of the inhibited respiration. 

Should this treatment result in severe spasm and cyano- 
sis, it must be temporarily abandoned and the patient given 
fresh air. As soon as breathing is again resumed the mask 
is reapplied. x 

There is no use in pouring ether at a patient, who is not 
breathing. ^fo 

After the mucous iflBnpranes have lost their sensitive- 
ness, careful administratiori of a vapor moderately concen- 



i' 



22 ANAESTHESIA 

trated will avoid spasm of the larynx, which may otherwise 
occur. 

When N 2 is used for induction ether should be given 
without removing the apparatus from the face. The C0 2 
of the respirations collecting in the apparatus deepen the 
respirations ( see page 299 ) . The deeper and freer the res- 
pirations, the easier it is to saturate the circulation with ether. 

The direct control of the excitement demands the pres- 
ence of one or more assistants. Someone besides the anaes- 
thetist should not only be present but unsterile. When the 
patient is on a stretcher, linen bandages or special restrain- 
ing straps are used. Upon a bed, sheets or blankets may 
be employed. 

The following is a case in which the anaesthetist " took a 
chance," and started anaesthetizing the patient without as- 
sistance at hand. The surgeon and nurse were " scrubbing 
up " in another room. The patient lay across the bed un- 
restrained, in preparation for an obstetrical operation. 
The induction progressed with perfect smoothness until all 
at once the patient developed sharp excitement. She 
laughed, threw her hands over her head, and tore off the 
face piece. She drew up her knees and writhed about, 
winding up in an inaccessible position parallel with the bed. 
She was with difficulty pulled back into place and the face 
piece reapplied, A moment later the bed spring gave way 
at the head of the bed and the patient slid into a hole, 
from which she was finally extricated before consciousness 
returned. After the operation she awoke quickly, without 
sickness and grateful for a delightful anaesthesia. 

Insist on having complete control of the patient's head. 

The author recalls a case in which he failed to insist 
upon this arrangement. The operation was for paracente- 
sis of the ear drum, complicated by a valvular lesion and 



COMPLETE GENERAL ANAESTHESIA 23 

poor compensation. Proper extension of the head was not 
obtained. Respiratory obstruction resulted, and when the 
anaesthesia was stopped the patient suffered from grave 
cardiac dyspnoea (see Fig. 11, illustrating the correct and 
Fig. 12, the incorrect control of the head). 

The sense of hearing persists after the loss of smell, 
taste, sight, and touch. This is particularly true when 
nitrous oxide is used. A short time ago a patient was 
anaesthetized with nitrous oxide and oxygen. When almost 
ready for operation, the surgeon said to the anaesthetist: 
"Let me know when you are ready.'' A few moments 
later the operation was performed, the anaesthesia being 
perfectly satisfactory. Upon recovery the patient re- 
ported that the last thing she knew was Dr. remarking : 

" Let me know when you are ready." 

One should be careful not to make any remark which 
may be remembered by the patient, or possibly arouse a 
subconscious fear. 

The direct control of the period of excitement may 
therefore be summarized as follows: 

1. By the concentration of the anaesthetic. 

2. By assistance to help restrain the patient. 

3. By the use of N 2 and a close apparatus for induction. 

4. By the proper control of the patient's head. 

5. By quiet in the anaesthetizing room. 

The Second Period of Induction : Rigidity 
Taking up the second period of induction,, rigidity, we 
shall consider its evidences, causes and control. 

A. Evidences of Rigidity. — Rigidity may be seen in 

all classes of muscles, in voluntary as well as in involuntary 

muscles. We may conveniently divide these classes into: 

(a) Those muscles which usually act under the direct 



24 



ANAESTHESIA 







Fig. 11. — Correct control of the head, the patient across the bed. 




Fig. 12.— Incorrect control of the head, the patient parallel with the bed. 



COMPLETE GENERAL ANESTHESIA 25 

control of the will, i.e., the muscles of the arms, legs, mas- 
seters. 

(b) Those muscles which usually act reflexly, i.e., the 
sphincter muscles, respiratory muscles, uterine muscles. 

Graphically we may describe the patient who is rigid 
as follows: 

The arms and legs tend to flex, the fingers are clenched, 
the muscles of the neck resist the effort on the part of the 
anaesthetist to turn the head to the side. The teeth are 
tightly closed, and it will be found that the lower jaw, when 
grasped, cannot be made to open freely. The respiration 
is usually obstructed and the accessory muscles of respira- 
tion stand out hard and prominently. The eyelids are 
tightly shut. The breathing is thoracic, the abdominal 
muscles, in vigorous subjects, showing clearly beneath the 
skin, tense and board-like. These signs may appear to- 
gether or separately. 

Pseudo-rigidity, or rigidity due to faulty position, ab- 
dominal distention and unusually well-developed muscu- 
lature, occasionally occurs. This should be recognized 
and differentiated from the rigidity which is due to incom- 
plete anaesthesia. 

Causes of Rigidity 

I. Prolonged 'Excitement from any Cause. — The ner- 
vous mechanism, whose activity gave rise to the stage of 
excitement, is the same power which furnishes the stimuli 
for muscular contractions. 

Rigidity is the tonic or tetanic contraction of muscle as 
a result of continuous stimuli. We see these stimuli in the 
early stages of excitement resulting in voluntary and 
occasional movements. Later the stimuli increase, be- 
come more frequent and of a clonic nature, conveniently 



26 ANESTHESIA 

spoken of as muscular excitement. Lastly we see the effect 
of an overwhelming flow of stimuli, giving rise to an appar- 
ently continuous contraction and resulting in what we 
term rigidity. This summation of stimuli not only causes 
the muscle to contract but also to become actually shorter. 

When we realize this hardening and shortening of the 
rigid muscle, particularly in the case of the abdominal mus- 
cles, we will easily understand how rigidity may interfere 
with intra-abdominal manipulations. 

2. Obstructed Respiration. — Obstructed respiration is 
one of the most constant causes of muscular rigidity for, by 
decreasing the tidal volume of the respired air, it prevents 
us from introducing the proper quantity of the anaesthetic 
into the circulation. The circulation must be saturated 
with ether to the extent of 1 to 400 parts or at a vapor ten- 
sion of 48 mm. (see page 64), before the full effect of the 
anaesthetic is obtained. In addition to this, a lack of suffici- 
ent oxygen per se is frequently the cause of rigidity. 

If the progressive increase is interfered with at the time 
of induction, the anesthetization is not only delayed but 
almost immediately becomes lighter, and in the presence of 
this lighter stage, vomiting and muscular rigidity often 
supervene. Induction must constantly progress to the 
stage of maintenance, if the best results are to be secured. 

We may conveniently consider obstruction to the res- 
piration as occurring: 

(a) Outside the respiratory system. 

(b) In that portion bounded externally by the nares 
and lips, internally by the epiglottis. 

(c) From the epiglottis to the bronchi. 

(d) From the bronchi to the alveoli. 

(a) Among the most common forms of obstruction to 
respiration occurring outside of the respiratory tract are: 



COMPLETE GENERAL ANAESTHESIA 27 

Improper apparatus with a restricted airway. The res- 
pirations should not be obliged to pass through a tube 
whose area is less than the trachea, or about % °f an inch. 
This is particularly true during the stage of induction,, 
when the respirations are increased in rapidity and volume. 
It will often be found that, even when the airway is free 
[before it is packed with gauze] after this has been placed 
in situ, this airway becomes very much restricted. 

External pressure should be avoided. Dressings placed 
in preparation for neck operations should be loose. Too 
tight strapping of the patient or the weight of assistants 
on the neck or chest will naturally obstruct the respiration. 

Intra-abdominal growths or fluid, by pressing against 
the diaphragm, may seriously affect the breathing. 

Within the respiratory tract, but external to the airway 
proper, pleurisy with effusion, empyema and enlarged 
bronchial glands frequently form complications, which 
must be thoughtfully dealt with. 

The position of the patient, Trendelenburg for pelvic 
work, prone for operations on the coccyx, all more or less 
embarrass the respiration. It is surprising, however, how 
well patients do in spite of the embarrassment, which their 
positions might suggest. The habitual semiprone or prone 
position in natural sleep may perhaps be accountable for 
the unexpected successes which we meet in these cases. 

(b) Obstruction occurring between the lips, nares and 
epiglottis. Obstruction to the respiration, which cannot be 
accounted for through external embarrassment, will usu- 
ally be traced to obstruction in this location, as from ade- 
noids, polypi, deviated septum, enlarged turbinates and 
paralyzed soft palate, which obstruct the nasal respiration. 

Oral obstruction may occur through teeth which coapt 



28 ANAESTHESIA 

perfectly upon themselves, or which are closed in spasm on 
the tip of the tongue. The lips of toothless persons, which 
flap valvelike to and fro without admitting air, paralysis 
of the tongue, which causes it to drop back into the pharynx 
and enlarged f aucial tonsils may also cause obstruction. 

(c) Obstruction occurring from the epiglottis to the 
bronchi. Obstruction here may be caused by oedema of the 
glottis, spasm of the vocal cords, giving rise to crowing 
respiration, external pressure of glands or goitre, mucous 
or vomited material inspired. 

(d) Obstruction occurring below the bronchi. This is 
caused by anything which involves the alveoli, as for exam- 
ple, pulmonary tuberculosis, pneumonia, asthma, bron- 
chitis, bronchiectasis or abscess of the lung. This type of 
obstruction will become evident by the fact that even with 
the oral and laryngeal respiration free and no cardiac in- 
sufficiency having been found, yet the patient tends to 
persistent cyanosis. 

3. Operations Begun Before the Skin Reflexes are 
Abolished. — This procedure, by sending a flood of sensory 
impulses to the cord and higher centres, may give rise to a 
reflex which results in tetanic muscular contractions or 
rigidity. This rigidity may be local or general, involving 
the general musculature or limited to the painful locality. 

4. Dilation of the Sphincters. — Even after anaesthesia 
has been well induced and satisfactory relaxation obtained, 
the dilation of the anal sphincter of primiparous cervix 
may give rise to stimuli, which are sufficient to send motor 
impulses along those nerves whose normal irritability has 
been hitherto lowered by the influence of the anaesthetic. 

Upon the cessation of this profound stimulation, the 
patient will be found to be in a satisfactory anaesthetic 



COMPLETE GENERAL ANESTHESIA 29 

state. If the amount of the anaesthetic has been increased 
so as to totally abolish all effects of this stimulation, when 
the dilation has been accomplished, the patient will be 
found to be unnecessarily " deep." Therefore, as long as 
these reflexes do not interfere with the surgeon, they may 
be permitted to persist. 

5. Manipulations in the Region of the Pelvis or Gall- 
Bladder. — In presence of a moderately deep anaesthesia, 
reflexes from these sources may, by increasing the depth or 
possibly obstructing the respirations, produce transient 
rigidity. Relaxation usually follows upon their cessation. 

6. Faulty Position of the Patient. — Pseudo-rigidity, or 
apparent rigidity, may appear where an improper position 
of the patient obtains. This is frequently the case where 
the desired position has not been completely obtained. 
Operation upon the neck, gall-bladder, kidney, coccyx and 
female pelvic organs occasion most of these embarrassments. 

7. Operation in the Upper Abdomen Per Se. — Com- 
plete relaxation in operations involving an incision through 
the upper abdomen is, as a rule, difficult to obtain. Thus, 
operations upon the stomach, pancreas, liver, spleen, etc., 
imply a profound anaesthesia, and special attention to the 
position and the respiration of the patient. 

8. Distention of the Abdomen. — In this case a pseudo- 
rigidity is likely to be seen when the closure of the wound 
is being done, the operation in itself having failed to relieve 
the distention, i.e., an operation for intestinal obstruction 
in obese patients. 

9. The Anaesthetic Used. — A certain degree of rigidity 
is quite constantly to be expected when the anaesthetic is 
nitrous oxide and oxygen. This holds good even during 
a stage of satisfactory maintenance. 



30 ANAESTHESIA 

We may then summarize the causes of rigidity as fol- 
lows: (1) Excitement; (2) obstruction to the respiration; 
(3) operations begun too early; (4) sphincter dilatation; 
(5) gall-bladder and pelvic manipulations; (6) faulty 
position; (7) operations on upper abdomen ; (8) distention 
of the abdomen ; ( 9 ) the type of anaesthetic used. 
^ Further Explanatory Notes on Rigidity. — The 
evidences of rigidity having become apparent and the im- 
mediate causes enumerated, it may not be amiss to consider 
briefly its deeper meaning as expounded by G. W. Crile 
of Cleveland. 

This investigator's altogether fascinating theories on 
shock will serve to throw some light upon the phenomena 
of that rigidity due to the pain of the first incision and the 
subsequent rigidity arising from reflex stimulation, such as 
dilation of the sphincters, manipulations about the gall- 
bladder or in the pelvis. 

According to Crile, among the most highly developed 
reflexes are those which respond to pain stimuli. In the 
normal man, to inflict physical pain is to imply a muscular 
reaction, an expression of reflex self-defense. For exam- 
ple, if the finger were cut or burned, the hand would imme- 
diately be withdrawn. When the skin of the abdomen is 
cut or when the peritoneum is irritated, the abdominal mus- 
cles become board-like. This rigidity comes about appar- 
ently for the purpose of protecting the deeper structures. 

Crile maintains that anaesthesia does not prevent the 
flow of afferent or pain sensations to the cord and brain. 

What the anaesthetic does do to a greater or less extent 
is to interfere with the motor power of the muscles nor- 
mally included in this reflex. 

If the pain stimuli of an early incision reach the cord 



COMPLETE GENERAL ANESTHESIA 31 

before the motor portion of the reflex arc has been com- 
pletely obliterated by the anaesthetic, the result will be the 
contraction of those muscles normally affected by this re- 
flex, and rigidity will result. Dilation of the sphincters 
gives rise to pain and results not only in muscular rigidity, 
but acts more deeply by affecting the respiration and more 
rarely the pulse. 

Since anaesthesia does not abolish the effects of actual 
pain upon the nervous system, the profound exhaustion 
and shock, which one would expect in the case of a pro- 
longed operation without an anaesthetic, also obtains in all 
operations with anaesthesia, the difference in the two cases 
being that with the anaesthetic the patient is spared the con- 
scious pain and unpleasant memories. 

Whether or not, and to what degree the pain impulses 
to the cord and brain are affected by the anaesthetic is still 
a matter for discussion. We may safely conclude, how- 
ever, that all irritability is not subdued, for manipulations 
about large nerve centres and undue roughness on the part 
of the surgeon will frequently cause shock even in the face 
of a brief and profound anaesthesia. The significance of 
rigidity associated with pain stimuli and its disappearance 
in the face of deeper anaesthetization is not, therefore, a 
license to unnecessarily damage or destroy tissue. 

If Crile's premises are true, profound anaesthesia is like 
obscuring abdominal pain by the use of morphine. It 
covers over but does not remove or cure the underlying con- 
dition, which in this case is not disease but surgical trauma. 

Local anaesthesia does prevent afferent stimuli or pain 
impulses to the cord or brain. If all necessary manipula- 
tions are done under cover of this nerve blocking, as is 
Crile's constant technic, and if all unnecessary trauma is 



32 ANAESTHESIA 

avoided, then a light anaesthesia becomes not only the 
method of choice but enables the surgeon to detect pain, 
which he may unwittingly occasion and desire to avoid. 

Rigidity then may have a deeper significance than 
would appear upon a superficial consideration. When 
caused by pain, it is more than a mere mechanical embar- 
rassment. It is a crying out on the part of the organism 
against the trauma which is being inflicted upon delicate 
and sensitive tissues. We deepen the anaesthesia and figu- 
ratively choke off this sign of the patient's resistance. 
The result, according to Crile, is the creation of an illusory 
protection, which in all likelihood the nervous system of the 
patient does not experience. 

C. The Control of the Period of Rigidity. — We 
have seen what evidences of rigidity we may expect. We 
have considered the most important causes of the condition. 
To imply the method of the removal of these causes is not 
sufficient ; we must patiently consider in detail the methods 
we will use to arrive at the desired end. The proper control 
of rigidity will tax the art of the anaesthetist to the utmost. 

1. Since excitement is one of the most common causes 
of rigidity, it may not be amiss to recall the control which 
was suggested for this stage, namely : 

»» t . . . t r For symptoms. 

Preliminary visit. J J r 

{ For suggestive therapeutics. 

' Diet. 
Sleep. 
Preliminary medication. <j Preliminary morphine. 

Beginning the anaesthetic on the 
operating table. 




COMPLETE GENERAL ANAESTHESIA 33 

Concentration f Dilute for coaxing. 

of \ Concentrated for 

anaesthetic. *■ driving. 

Direct { Attendants for restraining. 

Control of the head. 

Use of N2O and close apparatus. 

Quiet in anaesthetizing room. 

2. The Control of Obstruction to the Respiration. — 
The obstruction which is due to occlusion of the nasal air- 
way may be ignored by providing satisfactory respiration 
through the mouth. 

When the teeth are clenched, causing an obstruction 
which results in cyanosis and light anaesthesia, they must be 
separated or air otherwise introduced to relieve the spasm. 
It will be found that there is often a space between the last 
molar and the j aw. The finger may be introduced here and 
the tongue depressed. Occasionally a tooth is missing, 
which leaves a space for the introduction of the mouth gag 
or finger. One should be careful to protect the finger, other- 
wise a serious bite resulting in a septic wound may result. 

A large catheter or stomach tube passed through one 
of the nostrils into the pharynx often relieves the spasm. 

Finally, the teeth should be separated and a throat tube 
introduced. The best thing for this purpose is a boxwood 
wedge and tube, as shown in Figs. 13 and 14. 

The teeth are gently separated by the sharp edge of the 
wooden wedge. When sufficient space has been secured, 
the tube may be slipped into the mouth over the top of the 
tongue (Fig. 15). An adequate airway will thereby be 
immediately secured and the spasm and rigidity will pass 
off. It is impossible to laud too highly this tube, which may 
be called the " Sine qua non " of the anaesthetist. 
3 



34 



ANAESTHESIA 



Obstruction between the epiglottis and the bronchi. 
(Edema of the glottis, secondary to burns or inspiration of 
liquid ether, must be dealt with vigorously. Diagnosis of 
this condition is made by excluding nasal obstruction, 
laryngeal spasm, and a history, which might lead one to 
suspect obstruction below the epiglottis. One of two things 




Fig. 13. — The boxwood mouth wedge. 

must be done — intratracheal intubation or tracheotomy. 
Spasm of the vocal cords is a peculiar and annoying 
type of obstruction. Its causation is obscure and its relief 
often difficult. A hurried induction hampered by obstruc- 
tion is often its precursor. Occasionally it follows an inci- 
sion which has been made too early. A change of the anaes- 
thetic state to shallowness when the patient is deep, or 




Fig. 14. — The author's modification of the Connell throat tube. 

deeper when the anaesthesia is slight, is often beneficial. 
Strange as it may seem, if in the course of a comparatively 
deep anaesthesia with persistent crowing respirations, 
pelvic, gall-bladder or other deep reflex be stimulated, the 
crowing will lessen and often disappear. The attention of 
the nervous system has been distracted, so to speak. Rhyth- 
mical traction of the tongue may relieve this disturbance. 
Mucus, saliva and vomited material may be drained by 



COMPLETE GENERAL ANAESTHESIA 35 

the use of the Trendelenburg position or by the sucker, 
commonly found in the operating room (see page 323). 
Or the pharyngeal reflexes may be permitted to return 
and expel the foreign material. The preliminary use of 
morphine and atropine, by reducing the secretion and 
the irritability of the pharyngeal mucous membranes, 
often acts as a prophylactic against this type of obstruction. 

Obstruction due to glands 
and goitres must be dealt 
with in such a way that the 
period of excitement will be 
reduced to a minimum. Any- 
thing which tends to increase 
blood-pressure at the induc- 
tion must be avoided, as for 
example, the use of nitrous 
oxide without oxygen, or 

pushing the concentration J 1J 7lW( )j 

before the patient is deeply V / y\ Q 

enough " under " to accept it. ""\ J )sl C~fl 

The control of the obstruc- /ill fu 

tion occurring below the 

7 7 • r^i i i • 1 1 Fig. 15. — Throat tube in place. 

bronchi. Obstruction result- 
ing from pneumonia, asthma, etc., should be met by 
employing oxygen with the ether administration. 

3. Rigidity, which is caused by an incision made before 
satisfactory induction has taken place, will usually dis- 
appear on deepening of the anaesthesia. Unless occurring 
during consciousness, or associated with respiratory ob- 
struction, it need cause no alarm, if ether is the anaesthetic. 

4. Rigidity during the dilation of the sphincters, unless 
interfering with the surgeon, may well be permitted; for 




36 ANAESTHESIA 

this usually gives place to relaxation, when the excessive 
reflex has ceased. 

5. Transient rigidity, which occurs during pelvic and 
gall-bladder work, must be temporarily abolished, if it 
proves inconvenient to the surgeon. When these manipu- 
lations have been completed, the patient may be permitted 
to " come out " somewhat. The important point to be borne 
in mind is that the patient is not necessarily light if he shows 
some disturbance in the face of these profound reflexes. 

6. The position of the patient is such an important fac- 
tor in producing rigidity that it seems wise to illustrate 
comprehensively the positions most used. (Figs. 16-45). 

The Trendelenburg Posture (Figs. 16, 17, 18, 19, 
20). — The Trendelenburg posture is one in which the pa- 
tient lies on the back on a plane inclined about 45 per cent., 
the feet and legs elevated hanging over the edge of the 
table, the weight of the body supported by shoulder braces. ^ 
Table set for Trendelenburg position is shown in Fig. 16. 

The patient is first placed in the dorsal position upon 
the horizontal table. The knees are so placed in relation 
to the break in the foot of the table, that when the latter 
is dropped, the legs will be parallel to this portion. If the 
patient is not sufficiently near the end when the foot of 
the table is dropped, the knees will not be properly flexed 
and the feet will stick up in the air. If, on the other hand, 
the patient is too far down when the table is broken, she 
will not receive the proper support, for in this case she will 
rest entirely upon the shoulder braces. The patient should 
be pulled down toward the foot of the horizontal table 
until the break is about opposite the junction of the middle 
and lower third of the thigh. If the patient's calves are 
thick and muscular the distance should be greater than if 
they be emaciated and relaxed. 



COMPLETE GENERAL ANAESTHESIA 37 

When the knees are properly placed in relation to the 
break in the table (Fig. 17), the arms are extended, 
brought close to the patient's sides and the hands with the 
fingers extended are placed out of sight under the buttocks. 

The shoulder braces are next placed in position. 
They should invariably be used. Where the patient is 
obliged to support her weight by her knees, she is liable to 
develop paralysis by pressure upon the peroneal nerve. 

With the knees properly placed, the hands under the 
patient and the shoulder braces in place, the table is ele- 
vated and the feet are dropped. The position shown in 
Fig. 18 then obtains. 

Some operators believe that better abdominal relaxa- 
tion results if the knees are not flexed, as shown in Figs. 
19 and 20. 

The object of the Trendelenburg position is to secure 
better exposure of the pelvic organs by virtue of the dis- 
placement by gravity of the abdominal viscera. It is most 
advantageously used in thin sub j ects. It is contraindicated 
in cases presenting free pelvic pus. This position pro- 
duces engorgement of the blood vessels of the head and 
neck. The pharyngeal structures and the tongue are 
swollen and often give rise to obstructed respiration. 
Where there is danger of acute cardiac dilatation through 
a preceding acute infection or fatty degeneration, this posi- 
tion should not be used because of the increased strain 
thrown on the right heart. 

In fat people the use of this position has been followed 
by intestinal obstruction. Volvulus of the ileum and of 
the large intestine have also occurred. When the Trendel- 
enburg position has been employed, the omentum should be 
spread out in its normal position after the table is raised. 



38 



ANAESTHESIA 







Fig. 16. — Table in Trendelenburg position. 







Fig. 17. — Patient ready for Trendelenburg position. 



COMPLETE GENERAL ANAESTHESIA 




Fio. 18. — Patient in Trendelenburg position. 




Fig. 19. — Table in position for Trendelenburg position — feet straight. 










40 ANESTHESIA 

On the other hand this position presents many distinct 
advantages. It is the safest in which to administer chloro- 
form. Mucous and saliva which have collected in the 
pharynx drain off by gravity. In very sick cases the cere- 
bral circulation is thus best maintained. Patients, who 
have been carried upon a comparatively light anaesthesia 
in the horizontal position, frequently " come out " somewhat 
when the head is lowered. The converse is also true. 

The patient should be returned from the Trendelen- 
burg position to the horizontal slowly. If the horizontal 
is obtained too quickly, cerebral anaemia and circulatory 
shock may follow. 

Positions Favoring Paralysis (Figs. 22 and 23). — In 
addition to a pressure paralysis of the peroneal nerve, 
which has been taken up in connection with the Trendelen- 
burg position, we meet with two other rather common types 
of paralysis, secondary to an improper position on the 
table, namely, those of the brachial plexus and of the mus- 
culospiral nerve. 

Brachial Paralysis. — If the arms are abducted and 
extended over the head ( Fig. 22 ) , as sometimes occurs in 
the Trendelenburg position where the arms have been 
fastened on the breast and break loose from their fastening, 
or in a breast operation, where it is desirable to have the 
arms out of the way, a brachial paralysis is prone to follow. 
This shows itself as an Erbs palsy, the deltoid biceps, 
brachialis anticus and supinator longus being involved. 
In such a palsy the arms hang down by the sides and the 
forearm cannot be flexed. 

This type of paralysis is thought to occur from direct 
overextension of the brachial plexus ; in an Erbs paralysis 
the fifth and the sixth cervical nerves are chiefly involved. 



COMPLETE GENERAL ANAESTHESIA 



41 




Fig. 20. — Patient in Trendelenburg position — feet straight. 




Fig. 21. — The Simms position; patient on left side, left leg extended, right leg flexed, left arm 

behind and to the side. 






42 ANESTHESIA 

If the head be turned to the side during this process of 
overextension, damage is more pronounced to the plexus 
on the opposite side, since it is put on a greater stretch. 

Musculospiral Paralysis. — If the arm is permitted to 
hang over the edge of the table (Fig. 23), the musculo- 
spiral nerve may be compressed between the table edge and 
the bone and a paralysis results. This type of paralysis 
is quite common, but will never occur if the arms are prop- 
erly cared for. 

Recovery from posture paralysis is usually complete 
but protracted. Symptoms usually disappear first at the 
periphery, and later at the more central portions involved. 

Position for Operation on the Sacrum, Coccya? and 
Rectum (Figs. 25, 26, 27).— When the field of operation 
is posterior to the anus, the prone position (Fig. 25), or 
its modification as seen in Figs. 26 and 27, is best employed. 
The most useful of these three positions is the so-called 
sacral position shown in Fig. 27 

This position may be described as a sort of a reversed 
Trendelenburg. The control of the respiration in this 
position is not nearly as troublesome as might appear. If 
the head is turned to one side and the shoulder supported 
by a small sandbag, the respirations are entirely satisfac- 
tory. A lighter degree of anaesthesia may be carried in 
this position than in almost any other. 

This position is the best for coccyxectomy, resection 
of the rectum, spina bifida, etc. Where work is being done 
on the rectum a good exposure is afforded by the falling 
back of the abdominal viscera. The low position of the 
head is also a protection against shock, and mucus, which 
may collect in the throat, drains off by gravity. 

Posture for Kidney and Gall-bladder Operations (Figs. 






COMPLETE GENERAL ANAESTHESIA 



43 




Fig. 22. — Position favoring brachial paralysis. 




Fig. 23. — Position favoring musculospiral paralysis. 



44 



ANAESTHESIA 










Fig. 24. — Position for exploration of knee-joint. 




Fig. 25. — Prone position. 






COMPLETE GENERAL ANAESTHESIA 



45 




Fig. 26. — Prone position for sacral operation. 




Fig. 27. — Position for operation on sacrum. 



46 , ANAESTHESIA 

28, 29, 30, 31, 32, 33) . — While kidney operations are some- 
times done with the patient in the prone position, and while 
operations on the gall-bladder are frequently accomplished 
with the patient flat on the back, better exposure is had 
by employing the gall-bladder kidney rack (Fig. 28), or 
by breaking the table, as shown in Fig. 31. 

When the patient is placed upon the table she is made 
to lie over the rack or the break in the table, as the case 
may be. Breaking the table seems to be more satisfactory 
than employing a rack, as the patient does not so fre- 
quently complain of postoperative pressure symptoms. 

If a kidney exposure is desired, the patient is placed on 
her side. The under arm is carried behind her and pinned 
to the table ; the upper arm is flexed over the chest. 

The position of the legs is important. The upper leg 
should be extended ; the lower leg and thigh should be well 
flexed. This procedure will cause a slight tilting of the 
pelvis. The crest of the ileum will then be further away 
from the ribs on the upper than on the lower side, thereby 
increasing the field of exposure. 

With the arms and legs properly placed, the table is 
then broken or the rack is raised, as the case may be (Figs. 
29 and 32). 

If a gall-bladder exposure is desired, the patient is 
placed in the dorsal position over the rack with the arms 
to the side or folded over the chest, as in Figs. 30 and 33. 

Posture for Operation on the Neck (Figs. 34, 35, 36, 37, 
38, 39) . — Where an operation is to be performed upon the 
thyroid gland, the position shown in Fig. 34 is that usually 
employed. A small sandbag is placed under the shoulders 
and another under the nape of the neck. The head is held 
in the middle line. If the operation is to be for glands of 



COMPLETE GENERAL ANAESTHESIA 47 



Fig. 28. — Table with gall-bladder kidney rack in position. 




Fig. 29. — Patient in kidney position over rack. 



48 ANAESTHESIA 

the neck, the same technic is followed with the exception 
that the head is turned to the side instead. (Fig. 35.) 

The Elevated Neck Position. — In the elevated neck 
position the table is arranged as for the Trendelenburg 
(Fig. 37). In this case the head instead of the knees ex- 
tends over the foot of the table. 

The patient is placed on the horizontal table in such a 
manner that the head is at the foot of the table. The top 
of the shoulders are brought opposite the break in the lower 
leaf. A stout linen bandage is then passed about the feet 
and tied to the table suspending the patient in a sling ( see 
Fig. 38)' when the table has been elevated. 

The table is then thrown up and the head dropped, as 
in Fig. 39. The advantages of this position are as follows: 
There is less bleeding from the wound because of the eleva- 
tion; a certain degree of cerebral anaemia obtains which 
renders only a light anaesthesia necessary; the field of 
operation is brought near to the operator, who can thus 
work with greater ease.* 

The Rose position, shown in Fig. 36, is sometimes em- 
ployed for operation upon the tonsils and adenoids, the 
object of this position being to keep the blood and mucus 
out of the respiratory passages. 

The Lithotomy Position (Figs.' 40 and 41). — The 
lithotomy position is that ordinarily employed for obstetri- 
cal, vaginal, perineal and anal work. 

Where this position is employed for anal operations on 
strong, muscular patients or where only a light anaesthesia 
is to be administered, it is well to put the shoulder braces 
in place. This will prevent the patient from pushing her- 
self away from edge of table, should she become rigid. 

The buttocks should be extended well over the edge of 



COMPLETE GENERAL ANAESTHESIA 49 




Fig. 30. — Patient in gall-bladder position over rack. 




Fig. 31. — Table broken instead of raising rack. 




1 II 



50 



ANAESTHESIA 




Fig. 32. — Kidney position on broken table. 




Fig. 33. — Gall-bladder position on broken table. 



COMPLETE GENERAL ANAESTHESIA 



51 




Fig. 34. — Ordinary neck position for goitre operation. 




Fig. 35. — Ordinary neck position for glands of neck. 



52 



ANESTHESIA 







Fig. 37.— The elevated neck position. 



COMPLETE GENERAL ANESTHESIA 53 




Fig. 38.— The table set for elevated neck position. 




Fig. 39. — Patient in elevated neck position. 




54 ANAESTHESIA 

the table so that the weighted, vaginal speculum ordinarily- 
used may hang free. 

Anaesthesia may be induced with advantage in the 
lithotomy position where the operation is to be a curettage 
or some slight anal operation. By this method one need 
not wait for relaxation of the large thigh and calf muscles 
before preparations are begun. 

Posture for the Closure of Upper Abdominal Wounds 
(Figs. 42 and 43). — Complete relaxation for the closure 
of upper abdominal wounds is often difficult to obtain. If 
the head and the foot of the table are raised, as is shown 
in Figs. 42 and 43, relaxation will be materially assisted. 

The Watcher Position. — The Walcher or Hanging 
Position is purely for obstetrical purposes. The object of 
this position is to increase the diameter of the pelvic inlet 
by tilting the symphysis pubis, as shown in Fig. 44. This 
tilting increases the conjugata vera about one centimetre 
( Fig. 45 ) . The position is obtained by allowing the 
patient to rest on the edge of the table on the buttocks 
with her legs hanging free. ( Fig. 44.) 

7. Rigidity in upper abdominal operations is particu- 
larly embarrassing when the wound is closed. At this 
time great relief is afforded the surgeon by lifting the 
head of the table, thereby relieving the tension on the recti 

(refer to Figs. 42 and 43) . 

8. Rigidity caused by intra-abdominal distention, which 
has not been relieved by the operation, is best dealt with 
by using an open mask, at least during the stage of main- 
tenance. In this way the maximum oxygenation is 
obtained and there is practically no residual C0 2 to cause 
deep and embarrassing respirations. These cases are usu- 
ally quite sick and succumb easily to the anaesthetic. 



COMPLETE GENERAL ANAESTHESIA 



55 




Fig. 40.— Table set for lithotomy. 




Fig. 41. — Patient in lithotomy. 



5Q 



ANAESTHESIA 




Fig. 42. — Table set for closure of upper abdominal wounds. 




Fig. 43. — Patient in position for closure of upper abdominal wounds 



COMPLETE GENERAL ANAESTHESIA 



57 



9. Rigidity is caused by the anaesthetic per se: Where 
all rigidity must be abolished, nitrous oxide and oxygen 
alone will not give a uniform and satisfactory result in 
abdominal operations. Preliminary medication and nerve 
blocking or ether must be used. 




Fig. 44. — The Walcher position. 

The Third Period of Induction: Relaxation 
Relaxation is more than mere absence of rigidity. In the 
normal muscle, which is not rigid, there is a definite tone 
which differentiates it from the muscle which is completely 
cut off from the control of the central nervous system. 

A. The Evidences of Relaxation. — At the begin- 
ning of the stage of induction before excitement has become 
apparent, one frequently finds a condition of pseudo-re- 
laxation. The arms and legs can be flexed and extended, 
remaining quietly in place. Upon a casual observation it is 



58 



ANAESTHESIA 



almost impossible to differentiate this condition from that 
of true relaxation. In the case of children, where it is quite 
commonly found, it may sometimes be detected by sharply 
tapping the platysma myoides of the extended side ; if the 
patient is simply sleeping there will be a sympathetic dila- 
tion of the pupil of the same side. This condition of 
pseudo-relaxation may be accounted for in the following 
manner: During the period in question, the anaesthetic is 
producing chiefly cerebral effects or no effect at all. The 

10. 9 u-rrY motor nerves have lost none 

of their irritability. They 
are simply receiving no 
stimuli. The condition is 
much like that of natural 
sleep. Later the physio- 
logical effects of the ether 
become evident in a dis- 
charge of energy, which ex- 

Fig. 45.— Diagram to explain Walcher position, ViiVki + c i+ 0/a |-p i^ rronemal rvt» 
seep. 57. (After Williams' Obstetrics.) JllDltS ltSell in gend al Or 

local rigidity. Relaxation appearing shortly after the 
anaesthetic has commenced and which has not been preceded 
by a definite, however brief, stage of excitement should be 
regarded with suspicion. 

Occasionally true relaxation does come on in this man- 
ner, but this is unusual. 

The preliminary use of morphine may so far do away 
with the period of excitement that its presence is not noted. 
In such cases, true relaxation will come on with a quietness 
and rapidity which will strongly suggest the pseudo-state. 
One must not depend solely upon the evidences of relaxa- 
tion. These must be corroborated by the condition of the 
lid and eye reflexes. 




COMPLETE GENERAL ANAESTHESIA 59 

True relaxation may often be distinguished from the 
spurious by examining the condition of the masseters. It 
will usually be found that in true relaxation the lower jaw 
can be made to move freely up and down, while with 
pseudo-relaxation, the teeth are tightly clenched. 

B. The Causes of True Relaxation. — Relaxation 
may be said to occur when the deep muscle stimuli, which 
are constantly flowing to the normal muscle, have been 
inhibited by the action of the anaesthetic. 

This action, while affecting chiefly the nervous mechan- 
ism, may also be due to the direct effect of anaesthetic upon 
the muscle tissue, rendering it less responsive to stimuli. 

Whether or not the efferent motor mechanism is para- 
lyzed to the exclusion of the afferent sensory, as suggested 
by Crile, is still open for discussion. However this may be, 
we may account for muscular relaxation by supposing an 
anaesthetic " block " acting on the motor nerves. 

Loss of rigidity does not imply complete relaxation. 
We must, as already remarked, dispose of the normal tone 
of the muscle before the desired end can be obtained. 

C. The Control or the Relaxation. — If the pain 
stimuli are absent or diminished, the rigidity, which occurs 
as a reflex effect of this irritation will also be controlled. 
Local anaesthesia applied to the sensory nerve endings, as, 
for example, the injection of novocaine into the sensitive 
operative field, before incising, will result in an absence of 
rigidity on the part of those muscles, which would nor- 
mally be involved in this reflex. Under a light anaesthesia, 
such as that secured by nitrous oxide and oxygen there is 
no doubt as to this action. 

The control of the relaxation then is largely the duty of 
the anaesthetist, who will bring about the best results by 



60 ANAESTHESIA 

removing and controlling as far as possible the causes of 
rigidity, i.e., excitement, obstruction to the respiration, too 
early incisions, position of patient, operations on upper 
abdomen, gall-bladder and pelvic stimuli, dilatation of 
sphincter, anaesthetic per se and intra-abdominal distention. 

II. MAINTENANCE 

Having treated the first stage of a complete general 
anaesthesia, induction, we now proceed to the second stage, 
maintenance. 

The stage of maintenance begins when general relaxa- 
tion obtains, and when a constant depth of anaesthesia has 
been reached. It ends when the level, which has been held, 
is permanently permitted to drop. 

Two varieties of maintenance may be noted: the con- 
stant maintenance and the variable maintenance. 

Constant maintenance (Fig. 46) can only be obtained 
by means of a special mechanical device made for the pur- 
pose of delivering vapor in known percentages. 

Variable maintenance is the type which occurs when 
anaesthesia is otherwise carried on. 

Constant maintenance keeps the patient so completely 
anaesthetized throughout the operation that he will not 
inconveniently react to deeper stimuli. This type of anaes- 
sia protects the patient from afferent pain stimuli, and 
considers the amount of ether used as of little consequence. 

The varying type, which obtains when the open, semi- 
open or closed drop method is used,' aims to anticipate and 
hold in abeyance the reflex effects of trauma to the deeper 
structures, by increasing the anaesthesia according to indi- 
cations. It aims to lessen the amount of ether used by 
allowing a lighter level as often as possible. 

By a varying maintenance is meant one which varies 



COMPLETE GENERAL ANAESTHESIA 



61 



only under the immediate direction and control of the 
anaesthetist. The anaesthetist must always be in the " lead," 
so to speak. He must always know just where the patient 
is and anticipate the call for a lighter or deeper anaesthesia. 
For this reason he should be familiar with the operative 
procedure. He should know the technic and the demands 
of the surgeon with whom he works. Some surgeons ap- 
preciate a light anaesthesia, while others will not tolerate it. 



780 




M* INDUCTION j 
10 



MAI NTAI NANCE 
30 



RECOVERY 
30 



MIN. " MIN. 

Fig. 46. — Curve showing variable and constant maintenance; constant maintenance shown 
by dotted line, variable by solid. 

The anaesthetist should know something of the relative sen- 
sitiveness of the various tissues. He should know that the 
skin and the peritoneum react much more energetically 
than the muscle and bone tissues. With this knowledge, he 
will not be surprised in an operation for inguinal hernia, 
for example, to find the patient, who is going along peace- 
fully enough through the dissection of the involved mus- 
cles, suddenly come out of the anaesthesia when traction is 



62 ANAESTHESIA 

made upon the hernial sac, whose formation, it will be re- 
membered, is peritoneal. 

If we were positive that the amount of ether made no 
difference, from a pathological point of view, and if we were 
sure that a deep anaesthesia afforded an absolute nerve 
block, it would be very poor technic to use any method but 
that which will give a constant level. In view of the present 
theories touching upon nerve block and shock, however, and 
our incomplete information regarding the massive effects 
of ether on the blood and tissues, we are justified in feeling 
that this varying, or as is sometimes called, empirical 
method, is really not so unreasonable after all. 

The control of the stage of maintenance, as has already 
been stated, depends very largely upon the character of 
the induction. A stormy and delayed induction will very 
likely give rise to a stage of maintenance which is uneven 
and difficult to control. 

The obstruction of the respiration is one of the most 
important elements in the control of the stage of main- 
tenance. Persistent obstruction, during this stage, usually 
results in undesirable lightness with consequent rigidity, 
increased bleeding, and cyanosis. The paralysis of the 
tongue, which frequently causes this obstruction, can 
readily be relieved by the use of the throat tube (Fig. 14) , 
whose great value we once more emphasize. Other types 
of obstruction, such as laryngeal, pulmonary, intra- and 
extra-abdominal pressure, must be separately and success- 
fully dealt with, if one wishes a smooth maintenance. 

If the respiration is deep and free, the patient must be 
carefully watched for signs of recovery; for it will be 
readily appreciated that such a respiration will soon dis- 
pose of the ether which may be in the patient's circulation. 



COMPLETE GENERAL ANESTHESIA 63 

Such patients call for an increased amount of ether on the 
open mask or the continuous use of the closed method. 

On the other hand, the patient whose respirations are 
shallow is conserving most of the ether in his system and 
requires but a small amount to maintain the level in which 
we find him. This is quite typical of the patient who has 
received preliminary morphine medication. 

Occasionally one sees a patient in the stage of main- 
tenance forgotten for the time being by the anaesthetist, 
because of his lack of knowledge of the signs playing 
before his eyes, and because custom has, so to say, decreed 
that his work of " carrying the patient to the brink of the 
grave and leading him safely back again " is not quite: so 
important as holding the retractors and looking into the 
patient's belly. Such a neglected patient may do one of 
two things : If the anaesthetist wishes to make sure of not 
being disturbed during his observations, and as a safeguard 
against this annoyance, pours on ether without watching 
the patient, the latter may die, as has occurred not infre- 
quently under precisely such conditions. In this case the 
anaesthetist is not discharged from the hospital for criminal 
negligence, but the cause of death is registered as cardiac 
failure or status lymphaticus, which, however, does not 
clear the anaesthetist of serious guilt, due to his negligence. 
Or should the anaesthetist, bearing in mind these fatalities, 
in the course of his bird's-eye view of the field of opera- 
tions, stop giving ether for safety's sake, then the patient 
does the other of the two things — he vomits. This invaria- 
bly directs the condemning glances of the staff directly to 
the anaesthetist. As a result, anxious to cover up matters 
as quickly as possible, he does just the wrong thing. He 
immediately pushes the ether to the utmost. 



64 ANESTHESIA 

The onset of vomiting implies the return of the pharyn- 
geal reflexes. The reaction to ether is now much as it was 
in the early periods of induction; concentrated ether gives 
rise to spasm, rigidity, and delayed induction. The anaes- 
thetist, in his anxiety to bring the patient back to the stage 
of maintenance, defeats his own ends. The anaesthetic 
should be given slowly until a tolerance is established. It 
may then be pushed to the desired level without ill effects. 

While the stage of maintenance, therefore, may on the 
surface appear quite simple, it is fraught with danger to 
the patient and inconvenience to the surgeon, unless in- 
telligently carried out. 

From the surgeon's point of view the stage of main- 
tenance should have no varying levels. It should be 
absolutely smooth. When indicated, relaxation should be 
complete and respiration of such depth that it will not in- 
terfere with intra-abdominal manipulations. With the 
variable type of maintenance this ideal is approached and 
will become perfect according to the skill of the anaesthetist. 

With constant or unvarying maintenance, devised by 
Dr. Connell, it is the exception to fall short of this ideal. 

Constant maintenance implies the use of definite per- 
centages of ether. Technically such a percentage is spoken 
of as vapor tension. 

The Percentage or Vapor Tension or Ether. — A 
short explanation must be given of the physical laws which 
govern the transfer of ether from the liquid state in the 
ether can to the state of solution in the blood and nervous 
system of the patient. 

' The air around us exists under a pressure of one 
atmosphere and this pressure is expressed usually in terms 
of the height of a column of mercury that it will support — 



COMPLETE GENERAL ANAESTHESIA 



65 



namely a column of 760 mm. Hg which is known as the 
normal barometric pressure at sea level. Air is a mixture 
of gases and according to the mechanical theory of gas 
pressure each constituent exerts a pressure corresponding 
to the proportion of that gas present. In atmospheric air, 
therefore, the oxygen being present to the extent of 20 
per cent, exerts a pressure of 1/5 of an atmosphere or 1/5 
of 760 — 162 mm. of Hg. (A saturated atmosphere of ether 
vapor under like conditions exerts a vapor pressure of 
68 mm. Hg at- 20° C., 182 mm. Hg at 0° C, and about 
460 mm. at ordinary room temperature.) 






Induction. 



Recovery. 



Maintenance. 

Fig. 47. — Diagram showing vapor tension of ether in alveolar air during the 
three stages of a complete anaesthesia. 

' When a gas is brought into contact with a liquid with 
which it does not react chemically, a certain number of the 
moving gaseous molecules penetrate the liquid and become 
dissolved. As many molecules will penetrate the liquid in 
a given time as escape from it, and the liquid will hold a 
definite number of the gas molecules in solution, it will be 
saturated for that pressure of the gas. If the pressure of 
the gas is increased, however, an equilibrium will be estab- 
lished at a higher level and more molecules of the gas will 
be dissolved in the liquid. Experiments have shown, in 
accordance with this mechanical conception, that the 
amount of a given gas dissolved by a given liquid varies, 
the temperature remaining the same, directly with the pres- 
sure, that is, it increases and decreases proportionally with 

5 



66 ANAESTHESIA 

the rise and fall of the gas pressure. This is the law of 
Henry. On the other hand the amount of gas dissolved 
by a liquid varies inversely with the temperature. It fol- 
lows also from the same mechanical views that in a mixture 
of gases each gas is dissolved in proportion to the pressure 
which it exerts, and not in proportion to the pressure of 
the mixture. 

" Air consists in round numbers of four parts of nitro- 
gen and one part of oxygen. Consequently when a vol- 
ume of water is exposed to the air, the oxygen is dissolved 
according to its ' partial pressure,' that is, under a pressure 
of 1/5 of an atmosphere ( 152 mm. of Hg) . The water will 
contain only 1/5 as much oxygen as it would if exposed to a 
full atmosphere of oxygen, that is, pure oxygen. And on 
the other hand if water has been saturated with oxygen 
at one atmosphere 760 mm. of pressure and is then exposed 
to the air, 4/5 of the dissolved oxygen will be given off, 
since the pressure of the surrounding oxygen has been 
diminished this much. 

' When a gas is held in solution the equilibrium is 
destroyed if the pressure of this gas in the surrounding 
medium or atmosphere is changed. If this pressure is in- 
creased the liquid takes up more of the gas, as an equi- 
librium is established at a higher level. If the pressure is 
decreased the liquid gives off some of the gas. That pres- 
sure of the gas in the surrounding atmosphere at which 
equilibrium is established measures the tension of the gas 
in the liquid at the time. Thus when a bowl of water is 
exposed to the air the tension of the oxygen in the solution 
is 152 mm. Hg; that of the nitrogen 608 mm. Hg. If the 
same water is exposed to pure oxygen the tension of the 
oxygen in solution is equal to 760 mm. Hg, while that of 



COMPLETE GENERAL ANAESTHESIA 67 

the nitrogen sinks to zero if the gas that is given off from 
the water is removed. With compounds such as oxyhemo- 
globin the tension under which the oxygen is held is meas- 
ured by the pressure of the gas in the surrounding atmos- 
phere at which the compound neither takes up nor gives off 
oxygen. If, therefore, it is necessary to determine the 
tension of any gas held in solution or in dissociable com- 
bination it is sufficient to determine the percentage of that 
gas in the surrounding atmosphere and thus ascertain the 
partial pressure which it exerts. If the atmosphere con- 
tains 5 per cent, of a given gas the partial pressure exerted 
by it is equal to 38 mm. Hg (760 times .05) and this figure 
expresses the tension under which the gas is held in solution 
or combination in a liquid exposed to such an atmosphere. 
(If the atmosphere contains 6.58 per cent, of ether vapor 
the partial pressure exerted by it is 50 mm. Hg.) 

" It is important not to confuse the tension at which a 
gas is held in a liquid with the volume of the gas. Thus 
blood exposed to the air contains its oxygen under a ten- 
sion of 152 mm. Hg but the amount of oxygen is equal to 
twenty volumes per cent. Water exposed to the air con- 
tains its oxygen under the same tension but the amount of 
gas in solution is less than one volume per cent. Ten- 
sions of gases in liquids are expressed either in percentages 
of an atmosphere or in millimetres of mercury. Thus the 
tension of oxygen in arterial blood is found to be equal to 
about 10 per cent, of an atmosphere of 76 mm. Hg. " (The 
tension of ether vapor necessary to maintain anaesthesia is 
about 50 mm. Hg.) " — Howell ; matter in parentheses ours. 

Were it of advantage that a saturated atmosphere of 
ether at room temperature be breathed by a patient, so 
much ether could be dissolved in the blood that the vapor 



68 



ANAESTHESIA 



tension of the ether dissolved would finally equal that of 
the vapor in the lung, or 460 millimetres. Yet it is found 
clinically that a sufficient depth of anaesthesia has been 
achieved when the amount dissolved in the blood has a 
vapor tension of 50 millimetres. To insure this amount be- 
ing dissolved into the blood within a reasonable time, — six 
to eight minutes being usually employed in induction— it 



2lO mm 

150 mm 

120 mm - 

90"""- 

75 nun. 
50 mm 
30 m « 



TIME 
STAGS 



460 mm » SATURATION @ 22^ C 






ASPHYXIAL INDUCTION ZONE 

RAPID AND DANGEROUS 


ZONE FOR RESISTANT SUBJECTS 


/rapid 1nduction\ 
/ relaxation \ 

/ IN 7-IO MIN. \ 


/ • SLOW INDUCTION V \ 
// RELAXATION X\ 
// IN ia-15 MIN. <\ 


/{IRRITATION, MUCOUS \ 

/ (subconscious EXCITEMENT N. 


/fSLIGHT IRRITATION 
/(CONSCIOUS EXCITEMENT 


I s 




/(PUNGENT ODOR 
/ (CONFUSION AND SOMNOLENCE 


i 
i 

i 


^ -__^ ANAESTHETIC 


/TETHER ODOR 
/(SLIGHT CONFUSION 

1 

1 


i 

i 
i 
t 

i 
i 


T EQUILIBRIUM 


3-5 MIN. J^ 5-7MIN. 

( " "TNDUCTrON 


— iJ*- 


20-40 MIN > | < MANY HOURS 

" FUttr SURGICAL ~ANAESTHESIA~" „ 



FlQ. 48. — Vapor pressure of ether in tidal air for induction and maintenance of full anaesthesia. Partial press- 
ure of vapor in millimetres of mercury (Courtesy of Dr. K. Connell, Johnson's Surgery, Appleton.) 

is required that a much stronger ether vapor be breathed 
during induction than is needed merely to maintain anaes- 
thesia. (Figs. 48 and 49) . 

To induce anaesthesia rapidly, the vapor must be so 
abundant as to exert a vapor tension of at least 180 
millimetres (Figs. 48 and 49). This gradually crowds 
the required amount of ether into the blood and nervous 
system. When the blood approaches the proper satura- 
tion, as indicated by the signs of anaesthesia, the amount 



COMPLETE GENERAL ANESTHESIA 



69 



of ether present in the air breathed is gradually lowered 
until finally, in ideal anaesthesia, the pressure of ether vapor 
in the lung balances the tension of ether dissolved in the 
blood and the patient sleeps in quiet, uniform anaesthesia of 
the desired depth. This is finally achieved at a level of 50 
millimetres of ether tension; or by volumetric percentage 

I20r 



ANAESTHETIC EQUILIBRIUM 
ESTABLISHED AT 50 rnm 



Time 
AVERAGE ADULT 

PERIOD 




INDUCTION 



continuance: 



Fig. 49. — Plot of ether vapor pressure in pulmonary tidal air and ether tension in body in first 
hour of ideal anaesthesia. (Courtesy of Dr. K. Connell, Johnson's Surgery, Appleton.) 

6.58 per cent, of the air breathed should be ether vapor 
(Figs. 48, 49 and 50) . At this level, both the small child 
and robust alcoholic sleep in anaesthesia of proper depth. 
The foregoing facts throw light on the following : 
The value of warming liquid ether to promote evapora- 
tion (not the value of warming ether vapor, which is nil). 
Safety of the open drop mask with its hoar frost evapo- 
rating surface (much reduced evaporating temperature). 



70 



ANAESTHESIA 



The efficiency of the closed system of anesthetization 
(because of the heat from rebreathing) . 

The greater efficiency of using a warmed apparatus 
( warm metal ) for induction. 

If one sets an ether vapor bottle in water 100° F., the 
ether vapor which issues approaches 100 per cent, instead of 
being 60 per cent. ( 460 mm. of 760 mm. ) or less ( see p. 148 ) . 

If with the semi-open method the patient rebreathes a 
little, this increased heat serves to give us better control 
of the patient. 




Qmm 

TLME 

Fig. 50. — Plot of ether tension in body. Recovery stage after full ether anaesthesia. 
(Courtesy of Dr. K. Connell, Johnson's Surgery.) 

The Volume Employed. — Following the question of 
vapor tension or the strength of the ether vapor, the bulk of 
the vapor administered is our next consideration. In order 
that the respiration may be tranquil, a sufficient volume 
must be administered. The amount necessary varies ac- 
cording to the individual from 10 to 18 litres a minute. 

The indicator on the angesthetometer shows the volume 
which is being delivered, and we are provided with the 
means to regulate automatically the amount of ether added 
to each litre and the consequent percentage of ether vapor. 



COMPLETE GENERAL ANAESTHESIA 71 

The Pressure at which the Vapor is Delivered. — 
This vapor, which is now being delivered in sufficient vol- 
ume to fill all the requirements for tidal volume and at a 
percentage which is constantly under our control, must be 
administered to the patient at a pressure sufficient to carry 
it deep into the pharynx and to exclude atmospheric air. 

The necessary volume of 10 to 18 litres a minute 
should be delivered at a pressure of from 15 to 30 mm., 
according to the individual in question. The volume is in- 
tended to be in excess to the respiratory needs and this 
delivery, under the pressure mentioned above, practically 
provides the patient with an atmosphere of a known and 
constant percentage. 

We have now considered and explained vapor pressure 
or tension; seen the need of a vapor pressure of 180 mm. or 
more for the stage of induction, and have established a 
vapor pressure of 50 mm. as a safe and satisfactory press- 
ure for maintenance. For apparatus see Fig. 82. 

Control of Maintenance. — The control of main- 
tenance resolves itself into: First, the undivided and in- 
terested attention of the anaesthetist. Anything which has 
a tendency to interfere with this should be eliminated, as 
trouble is certain to follow sooner or later. Second, the 
patient must be the final index governing the quality and 
the amount of the anaesthetic. The patient must never be 
forced against all his protecting signs to accept what 
is theoretically correct. The art of anaesthesia does not 
permit us to court the patient's death in this fashion. If, 
for example, the surgeon complains of rigidity during the 
course of maintenance, remarking, " Won't you please get 
him under," or " he is like a board," or simply stops his 
procedure and looks at you in unutterable disgust, do not 



72 ANESTHESIA 

soak the patient with ether in the presence of a dilated 
pupil, absent corneal reflex, and cyanosis. Be absolutely 
certain that you know the cause of the rigidity. Be sure 
that the respirations are free and that the position on the 
table is good ; that the patient is really light before you go 
ahead, and to protect yourself from abuse, give him the last 
push which sends him " over the brink." You are the pilot 
on the ship Patient. It is your duty to look out for the 
shoals and the breakers which threaten her course. Who 
ever heard of a trustworthy pilot leaving the wheel to lose 
himself in some diversion going on aboard? Do not let 
your first warning be a scraping of the keel as she rides over 
shallows, that is to say, when the patient begins to retch ; or 
the sudden startling sound of breakers, as the respirations 
become sighing and cease, and cyanosis becomes deeper and 
deeper, the eyelids widely separated and the pupils, with 
the iris almost gone, staring through a lustreless cornea. 
Unless one is a careful and observant pilot all the time, he 
will find himself drifting from the course and endangering 
the life of this human being so wholly under his control. 

We must realize that this business is a most serious one ; 
that its frequent execution by the youngest and most inex- 
perienced interne is a most unjust thing. That in this mat- 
ter the house officers, who incidentally rank above you and 
who have given a few hundred anaesthetics are not so expert 
that from their position at the retractors they can give you 
precise long-distance information as to the immediate needs 
of the patient. The color, the respirations, the pulse and 
the eye signs are our masters. Learn well how to obey 
these and all will go smoothly. If the surgeon and the 
senior house officers would force the anaesthetist to study 
the signs carefully and to be personally responsible for 



COMPLETE GENERAL ANESTHESIA 



73 




74 ANAESTHESIA 

everything incidental to the anaesthetic, accepting freely, 
in case of doubt, the opinion of their pilot, a smoother and 
a safer anaesthesia would result. 

We have considered the onset of the stage of mainte- 
nance, the constant and variable types available for our 
use and the responsibility of the anaesthetist towards the 
patient. Let us now take up the question: When does 
the stage of maintenance properly cease and the stage of 
recovery begin? 

Maintenance ceases when we leave the constant or vari- 
able level, which we have held and reduce or stop the anaes- 
thetic with a view of bringing the patient back to con- 
sciousness. While carrying on a variable maintenance, we 
may reduce and even stop the anaesthetic ; but we do not do 
this with a view of bringing about the complete recovery 
of the patient. The motive which leads us to finally stop 
the anaesthetic is that which really constitutes the dividing 
line between the stages of maintenance and recovery. 

III. THE STAGE OF RECOVERY 

This stage begins with the permanent reduction of the 
anaesthetic and ends with the return of consciousness. 

Because the inception of recovery is largely automatic, 
this stage of anaesthesia is likely to suffer from dangerous 
neglect. The anaesthetist is very apt to feel that when he 
ceases to give ether his responsibility is at an end, whereas 
his release does not come until consciousness returns. 

We may conveniently consider the evidences, types and 
control of the stage of recovery. 

A. The Evidences of the Stage of Recovery. — 
The stage of recovery becomes evident: (a) in the gradual 
and complete return of the reflexes; (b) in the return of 
consciousness. 



COMPLETE GENERAL ANAESTHESIA 75 

(a) One of the first signs to appear, upon allowing 
the patient to recover, is a slowing down of the respira- 
tions. These will drop from 40 to 25 or 20 a minute. The 
pupil, which has been moderately dilated during the stage 
of maintenance, will contract. That which has been smaller 
than normal will become pin-point or widely dilated from 
sympathetic stimuli. There will be rolling of the eyeballs, 
also active lid and corneal reflexes. One may also expect the 
pulse to increase in rapidity. Rigidity will show itself in 
the masseters and in increased intra-abdominal tension. 
The patient will swallow, and, shortly after this, retch. 
Vomiting usually marks complete return of reflexes. 

(b) Following the vomiting, which occurs upon the re- 
turn of the reflexes, there may be a period of quiet, during 
which time the patient is slowly recovering consciousness. 
If this period of quiet does not follow upon several attacks 
of vomiting, the patient may develop either protracted cy- 
anosis and vomiting, or on the other hand, may become 
pallid with barely perceptible pulse and shallow breathing. 

B. The Types of Recovery. — The chief cause of re- 
covery is, of course, the withdrawal of the anaesthetic. 

We recognize two types of recovery (see Figs. 52 and 
53). (a) recovery by crisis; (b) recovery by lysis. 

(a) Recovery by crisis (Fig. 52) is that type of re- 
covery in which the interval extending from the end of the 
stage of maintenance to the return of consciousness is very 
brief. This type of recovery is of course most desirable. 
Instead of coming about in the course of hours it takes 
place in minutes or seconds. The best example of recovery 
by crisis is found in gas oxygen anaesthesia. With this 
anaesthetic a patient, who has been held in the stage of 
maintenance for two or three hours, will recover conscious- 
ness in as many minutes. 



76 



ANAESTHESIA 



(b) Recovery by lysis (Fig. 53) is a common occur- 
rence in hospital anaesthesia where the anaesthetist uses a 
high level of maintenance to the end of the operation. 
Patients who experience this type of recovery may not 
regain consciousness for four or five hours after the end of 
the stage of maintenance. The most marked cases of this 
type of recovery are found in diabetic patients. Occasion- 
ally these patients never recover consciousness. 





/! 




T\ 


1 


f \ 




iXl 


1 






inl 


1 






i°\ 


1 






o\ 


1 






<\ 


1 






m\ 


1 






X\ 


/ 






| A 


10 




ZO 


1 

S-J-3 


MIN. 


"**"*•* 


MIN. 


'"MIN. 



Fig. 52. — Recovery by crisis. 

The following factors tend to induce recovery by crisis: 
nitrous oxide oxygen anaesthesia ; deep, free, rapid respira- 
tions ; alcoholism ; a short stage of maintenance ; the use of 
closed method with good oxygenation and employment of 
rebreathing ; the surgeon who permits early recovery. 

The following factors tend to produce recovery by lysis: 
ether anaesthesia ; a long stage of maintenance; preliminary 
morphine medication; acidosis; shallow or obstructed res- 
pirations ; the use of the closed method with persistent high 
maintenance and cyanosis. 

C. The Control of the Stage of Recovery. — The 

control of the stage of recovery divides itself naturally into : 

(a) that portion dating from the onset of the stage to the 



COMPLETE GENERAL ANAESTHESIA 



77 



time when the reflexes have completely returned ; ( b ) that 
portion dating from the complete return of the reflexes to 
the return of consciousness. 

We recognize these two periods of recovery because this 
division naturally comes about in the treatment of the pa- 
tient. Before the reflexes have returned the patient is un- 
der the immediate supervision of the anaesthetist. After 
the complete return of the reflexes he usually passes into 
the hands of the nurse. 




— +*■- 

MIN 



MIN. 
Fig. 53. — Recovery by lysis. 



(a) The first period of the stage of recovery should 
take place in the operating room on the operating table. 
The vomiting, which accompanies the return of the re- 
flexes, should be over by the time the patient leaves the 
operating room. 

Some patients do not vomit upon the return of the re- 
flexes, but the large proportion who do not at least retch 
once or twice. It will be understood that at this time, con- 
sciousness having not yet returned, such retching and vom- 
iting are not distressing to the patient. 

Our chief problem in controlling the stage of recovery 
is to determine when to begin. The exact time at which 



78 ANAESTHESIA 

the anaesthetic may be stopped is governed largely by ex- 
perience. This is one of the features which go to make up 
the Art of Anaesthesia. Broadly speaking, in the case of 
abdominal operations, a moderate level of maintenance 
having been carried, the anaesthetic may be permanently 
reduced as soon as the fascia is closed. When the surgeon 
begins to sew up the skin the face piece may be removed. 
In operations other than intra-abdominal, the anaesthetic 
may be reduced at an earlier period, the index in these cases 
being the comfort and freedom of the surgeon from objec- 
tionable signs, as rigidity, vomiting, movement, etc. 

If the throat tube has been in use during the course of 
the operation, it should be left in place until retching 
begins. By maintaining a free airway, an early recovery 
is thus obtained. If the Trendelenburg position has been 
used, when the head of the table has been raised, a lessened 
cerebral circulation will result. If this position be ex- 
aggerated as in the case of upper abdominal operations, the 
pulse should be carefully observed for shock. The anaes- 
thetic may also be reduced and withdrawn at an earlier 
period. If the induction has been stormy, and the main- 
tenance controlled with difficulty, the anaesthetist should 
pay particular attention to the patient during the stage of 
recovery, for there are likely to be attacks of vomiting ac- 
companied by masseteric spasm and distressing cyanosis. 
If this trouble is anticipated, the mouth tube should be held 
in place until the reflexes have returned to such a degree 
that the active laryngeal reflexes will not permit of the 
inspiration of vomited material. 

( b ) It will readily be appreciated that the second period 
of recovery (after the reflexes have returned) will be in- 
fluenced by the fact that the operation has been done in the 



COMPLETE GENERAL ANAESTHESIA 79 

home instead of in the hospital. In this case, unless speci- 
ally trained nurses be available, the patient must be 
watched carefully until consciousness has returned. The 
return of consciousness need not consist of a complete 
orientation, a clear-cut appreciation of all that has taken 
place. It is sufficient that the patient answers questions 
intelligently. It is sufficient that she "has found herself," 
so to speak. As the patient approaches the anaesthetic 
somewhat confused by the action of the preliminary mor- 
phine, so it is not only permissible but advantageous to 
leave her in some confusion regarding her condition and 
somewhat irresponsive to the pain which would otherwise 
torment her. 

Ninety-nine cases out of one hundred would probably 
make an uneventful recovery, if abandoned to themselves 
after the reflexes have returned. The remaining one might 
die. Is it not worth the possible saving of one life in a 
hundred cases to watch carefully the recovery of each? If 
that life was ours there would be but one answer. 

The recovery may worry us either because the patient 
develops continual spasm, cyanosis and vomiting, or, on 
the other hand, because of pallor, almost imperceptible 
pulse, and a slow and very shallow respiration. 

The first trouble is usually noticeable at once. In this 
case the wooden mouth gag may be introduced, the teeth 
separated, and tip of tongue pulled forward for a mo- 
ment by grasping it with gauze or with an ordinary sponge 
forceps. If it is impossible to separate the teeth, or if there 
is not room enough behind the last molar and the ascending 
ramus of the jaw to pass in the finger and depress the 
tongue, then a large catheter, moistened with the patient's 
saliva, should be passed through one of the nostrils by the 



80 



ANESTHESIA 



seat of obstruction into the laryngopharynx. Air is what 
patient needs and when it is admitted the spasm will pass. 
As the olfactory sense returns, the patient, upon smell- 
ing her expirations laden with ether, will often vomit re- 
flexly. This type of vomiting frequently responds to 
treatment designed to obscure the odor or reduce the re- 
ceptive powers of the olfactory mucous membrane. A 
piece of gauze moistened with vinegar, essence of orange 




Fig. 54. — Gauze on upper lip moistened with essence of orange. 

or some aromatic oil, placed on the upper lip, will often 
produce the desired result (Fig. 54) . 

The author recalls a recent case in which this particular 
form of reflex vomiting was relieved by inhalations of es- 
sence of orange. The patient, a rather high-strung young 
woman, had previously been twice anaesthetized by ether. 
Her recovery and post-anaesthetic period were character- 
ized by persistent and distressing vomiting. Following a 
subsequent and rather prolonged ether anaesthesia with a 



i 



COMPLETE GENERAL ANAESTHESIA 81 

high level of maintenance, the patient gave signs of 
recovery by crisis. The reflexes returned rapidly and she 
retched and threatened to vomit. As she began to retch, 
essence of orange on a gauze wipe was placed over her nose 
and mouth. The retching stopped at once and did not re- 
turn ; the subsequent recovery was entirely tranquil with a 
single brief attack of retching after an interval of hours. 

The second class of patients, those who suddenly de- 
velop imperceptible pulse and very shallow respirations 
after the return of the reflexes, act in response to compli- 
cations which are obscure and difficult to meet. 

This change usually comes suddenly, following in the 
course of a normal induction and maintenance and early 
recovery. It may be seen in the robust as well as in the 
delicate. An unusually profound reaction to morphine, 
loss of C0 2 , or a condition resembling ordinary syncope, 
may bring about this condition. Such patients, however, 
usually pass on to an uneventful recovery. 

When the nurse is placed in charge of the patient in the 
second stage of recovery, she should be instructed to keep 
the patient well blanketed, to watch closely the color, the 
respirations, and the vomiting. She should note carefully 
the position of the hot water bags, which have been applied 
to the patient. Continuous cyanosis, shallow, slow respira- 
tions (10 or less per minute) should be reported at once. 
When vomiting occurs, the patient should be placed on her 
side and the head extended. If there be pallor, with rapid 
running pulse, indicating possibly internal hemorrhage, the 
physician should be summoned promptly. 

The sooner consciousness returns, the better the patient 
is able to cope with his condition. Generally speaking, we 
may say that recovery by crisis argues well for the final 
and uncomplicated surgical recovery. 



CHAPTER III 
THE SIGNS OF ANESTHESIA 

The signs of anaesthesia may be considered under five 
headings : the respiratory ; the color; the muscular; the eye; 
and the pulse. 

During the periods of excitement and rigidity, we are 
concerned chiefly with the first two, the respiration and the 
color. As anaesthesia progresses, the muscular signs be- 
come of value, later the eye sign and lastly the pulse. 
During the early periods of induction, the respiration and 
the color must be under satisfactory control. The phe- 
nomena exhibited by the other groups at this time are but 
incidental and of negative value. That is, they but serve 
to show us that the patient is not under the influence of 
the anaesthetic. As anaesthesia progresses, however, these 
signs become of positive value by assuring us that the 
patient is under the influence of the anaesthetic and in our 
control. 

I. THE RESPIRATORY SIGNS 

Perhaps the most important single sign of this group 
is the respiration. We should watch the respiration 
closely from the beginning of induction to the end of re- 
covery. We should be intimately acquainted with the nor- 
mal respiration and be able to detect any deviation from 
the normal limits by the sound alone. Experience lends 
one a sense of safety which becomes so acute that abnor- 
malities grate upon the hearer and spur him to relieve that 



THE SIGNS OF ANAESTHESIA 83 

which he might otherwise suffer to persist. On the other 
hand this experience will also breed confidence and delib- 
erate action in circumstances which might otherwise ter- 
rify and lead to manipulations, dangerous and injurious 
to the patient. For example, a moderate but persistent de- 
gree of obstruction might be unnoticed by the beginner, 
while the experienced man, by making use of the throat 
tube, will relieve this obstruction and secure a much de- 
sired relaxation. On the other hand, during the stage of 
induction, the beginner may become terrified by a duski- 
ness, which is not really dangerous, and break a tooth in 
an effort to relieve a spasm, which would otherwise have 
passed off spontaneously without active interference. 

We may consider the normal respiratory phenomena 
by noting the rate rhythm and amplitude, during the stages 
of induction, maintenance and recovery, as exhibited when 
the open and closed methods are respectively used. 

The Normal Respiration Under Ether When the 
Open Method is Used. — When anaesthesia is induced by 
the drop method, the respirations are at first of normal 
rate, rhythm and amplitude. As the patient passes into 
the period of excitement, the rate increases and the rhythm 
remains constant, and the breathing becomes deeper. As 
anaesthesia progresses, the rate increases, the rhythm be- 
comes slightly irregular while swallowing and some hesita- 
tion is prone to occur. The amplitude will vary from a 
scarcely noticeable respiration to a deep, free breathing. 
As the stage of maintenance is reached, the rate will in- 
crease to 35 or 40 respirations a minute ; the rhythm will be 
resumed, and the breathing will be deep with a stertor of 
varying intensity. The first incision will produce no no- 
ticeable effect. As maintenance progresses the rate will 



84 ANAESTHESIA 

continue constantly between 40 and 50 a minute. The 
rhythm will be occasionally interrupted by gall-bladder 
work, when there will be an expiratory grunt, and by pelvic 
work, when there will be an inspiratory sighing. When 
work is being done on the stomach and intestines, the 
rhythm will usually remain undisturbed. The amplitude 
will have a tendency to become less as the stage of mainte- 
nance progresses. The degree of this shallowness will de- 
pend upon the extent to which rebreathing is permitted 
and upon the integrity of the diaphragm. As anaesthesia 
progresses the respirations are likely to become more and 
more shallow, but remain regular in rhythm. The stage 
of recovery having developed, the rate of respirations will 
decrease, the rhythm will become halting, and the breathing 
will become quite shallow. 

The Normal Respiration Under Ether When the 
Closed Method is Used and N 2 is Employed. — Almost 
immediately following the application of the face piece, 
the respirations will become rapid, regular, and much 
deeper than normal. This is due to the specific effect of 
the N 2 0, creating what is known as the " besoin de respire," 
or the necessity to breathe. If ether is now given cau- 
tiously, but with constantly increasing strength, the patient 
will shortly lapse into a stertor. As air is permitted, the 
rate will fall somewhat, but the rhythm will continue and 
the depth will be somewhat less. Under these conditions 
we pass into the stage of maintenance. Here we will ex- 
perience differences due to rebreathing and dependent upon 
the regularity with which our apparatus permits us to de- 
liver ether. If we pour in a large amount at long intervals, 
the respirations will be slow, spasmodic and shallow imme- 
diately upon receiving the dose, smoothing out as the toler- 






THE SIGNS OF ANAESTHESIA 85 

ance is established. Small doses often repeated tend to 
produce undisturbed respirations. 

Briefly, during the stage of induction,, when the closed 
method is used, the respirations are more rapid and deeper. 
During maintenance, rythmical and deeper ; during recov- 
ery, more rapid, regular and deeper. 

It will be seen that these variations from the open 
method are advantageous, since deep respirations give us 
better control of the patient. 

Respiratory Abnormalities Which are Likely to 
Occur When Both the Open and Closed Methods 
are Used. — We may take up separately the abnormalities 
occurring in induction, maintenance and recovery. 

Abnormalities which may Occur During the Stage of 
Induction: Rate. — The patient may scarcely breathe, ex- 
cept in a very shallow, superficial sort of way, or, on the 
other hand, the respirations may be very rapid. The former 
conditions will sometimes occur in women who have had 
morphine; the latter will be frequently seen in children. 
With a view of securing a speedy induction, rapid breath- 
ing will of course be advantageous. Slow breathing will 
delay the completion of anaesthesia, and frequently be 
accompanied by vomiting. The use of a closed ether 
apparatus with a gas ether sequence usually overcomes the 
embarrassment incident to this type of respiration. 

Rhythm. — Unless care is exercised to avoid all occa- 
sions of excitement, especially over concentration of ether at 
the outset, spasm of the respiration is almost sure to occur. 
This implies a respiration which is jerky in character, with 
a varying degree of obstruction. Such unsatisfactory 
rhythm will automatically adjust itself when the obstruc- 
tion is overcome and the anaesthesia deepens. Broadly 



86 ANAESTHESIA 

speaking, true relaxation and satisfactory maintenance do 
not co-exist with a spasmodic, obstructed respiration. 

Amplitude. — A reduction in the necessary volume of 
the respired air will result in delayed induction. One of 
the most frequent causes of the patient not " going under " 
is the lack of deep respirations. The tension or the per- 
centage of ether in the blood depends entirely upon the 
amount which is offered to the circulation at the walls of 
the pulmonary alveoli. If the breathing is superficial, the 
ether enters only the trachea and larger bronchi, and must 
depend entirely upon diffusion to reach the finer alveoli. 
This type of induction frequently occurs when the open 
method is used, and also where the face piece of the closed 
apparatus is not in contact with the face at the bridge of 
the nose and under the cheek. Such cases seem to be going 
along favorably, the breathing is quiet and the color is 
good, sometimes a slight stertor is heard. As preparations 
are made to scrub up, however, the patient will suddenly 
make a smothered remark and begin an active period of 
excitement. 

During the stage of induction the patient must breathe 
rapidly, rhythmically and deeply, if the best results are to 
be obtained. 

Abnormalities which may Occur During the Stage of 
Maintenance. — Rate. — When the stage of maintenance 
has been entered into, the rate of the respiration may sud- 
denly increase or drop as the skin is incised or the peri- 
toneum is opened. If this increase is co-existent with ab- 
dominal rigidity, the level of the anaesthesia must of course 
be raised, otherwise a change in rate may be ignored. This 
sign is often a valuable index to the true depth of the anaes- 
thesia. If the patient does not react to these manipula- 



THE SIGNS OF ANAESTHESIA 87 

tions, he is to be considered under satisfactory anaesthesia, 
even though the other signs of lightness may be present. 
Excessively rapid breathing occasionally develops. When 
the respiration increases to 50 a minute, the anaesthetic 
should be stopped, even though some signs of lightness 
may exist. One will usually find this rapid respiration 
co-existing with an absent corneal reflex, dilated pupil, 
and muscular relaxation. As a rule, withdrawal of the 
anaesthetic is quickly followed by a reduction in rate. Very 
sick patients, those who are septic or who have suffered 
from hemorrhage, will often react in this manner in the 
face of a light anaesthesia. If the relaxation be satisfactory, 
one should always keep these patients upon the lightest 
possible anaesthesia. Unusually slow respiration in the 
presence of signs of deep anaesthesia may be due to the 
effect of morphine or too much rebreathing. This sign 
is particularly distressing because it is so difficult to 
treat. If occurring where the open method is employed, 
morphine having been used, the closed method should be 
resorted to, in the hope that the accumulated C0 2 will serve 
to stimulate the respiration. If following in the course of 
excessive rebreathing, the condition may be due to a depres- 
sion of the respiratory centre by the use of too much C0 2 
or to lack of oxygen. Patients who do not react to re- 
breathing should be given a hypodermic of 1/100 gr. of 
atropine. 

Rhythm, — The rhythm of the respiration during the 
stage of maintenance is either a source of comfort or the 
occasion of much anxiety. Disturbances of rhythm occur- 
ring upon gall-bladder or pelvic manipulation are usually 
reassuring, as they indicate a moderate lightness of anaes- 
thesia. Respirations which lack rhythm from unknown 



88 ANAESTHESIA 

causes frequently indicate deep-lying trouble. Cerebra] 
hemorrhage into the base, pulmonary embolus or overdos- 
ing with ether will often show itself by such a form of dis- 
turbance. Occasionally one meets with Cheyne- Stokes 
respiration. The author recalls such a case, in which 
Cheyne- Stokes respiration immediately preceded a fatal 
issue. 

Disturbances of rhythm often occur where the level of 
the anaesthetic has been permitted to drop, the ether having 
been partially or completely withdrawn. In such a case, 
upon the reapplication of the mask into w T hich ether has 
been poured, the respiration will become spasmodic. If 
the level has been very low, complete stoppage may result, 
followed by spasmodic breathing until the patient is once 
again anaesthetized. If the level is higher, the effect will be 
a temporary slowing, followed by an increase in rapidity. 

Amplitude. — The amplitude of the respiration in the 
stage of maintenance appears to depend upon the action of 
the diaphragm and the presence or absence of C0 2 . 

If a closed method is used, the breathing will be deeper 
throughout. If open, the reverse is true. If the level of 
the maintenance is moderate, 50 mm., the action of the 
diaphragm is vigorous and the respirations are deep; if 
the level is high, 80 mm., the action of the diaphragm is 
progressively affected and the respiration is shallow. 

During upper abdominal operations, we must try to les- 
sen the respiratory effort so that abdominal movement will 
be reduced as much as possible. First of all the respira- 
tions must be unobstructed. The consequent limitation of 
oxygen and the accumulation of C0 2 in these cases cause 
embarrassing movements of the diaphragm. If the res- 
pirations are as free as possible, and the abdominal respira- 



THE SIGNS OF ANAESTHESIA 89 

tion is still annoying, we must partially paralyze the action 
of the diaphragm by raising the level of the maintenance. 
In this connection we may speak of the danger of trying 
to secure such relaxation where nitrous oxide and oxygen 
is the anaesthetic. In this case ether must be used. The 
securing of a higher level of maintenance in such cases 
should proceed with caution and in compliance with the 
signs of deep anaesthesia, as exhibited by the other signs 
of anaesthesia which we have at our command. The free 
use of oxygen often leads to decreased respiratory efforts 
and the desired result is thus obtained. This treatment 
should always be followed, and when successful is always 
preferable to raising the level of the anaesthetic. Occasion- 
ally when absolute freedom of the respiration obtains and 
no rebreathing is permitted, the patient will cease to 
breathe. This apncea may continue for a minute or two. 
When enough C0 2 has accumulated to stimulate a respira- 
tion, the patient will breathe spontaneously. If cessation 
of the respiration occurs in the presence of good color, pulse 
and eye signs, which show a moderate degree of anaes- 
thesia, one need not worry, for there must be other signs of 
depression before the patient is really in danger. 

The Trendelenburg position often affects the ampli- 
tude of the respiration. This is particularly true of large, 
fat subjects. A low level of maintenance in these cases will 
cause embarrassing abdominal respirations. A high level 
will be prone to result in respirations which are alarmingly 
shallow. 

Abnormalities in the Respiration which may Occur 
During the Stage of Recovery. — In the first half of re- 
covery : 

The rate of the respiration during the first half of the 



90 ANAESTHESIA 

stage of recovery, that is, to the complete return of the 
reflexes, is subject to the amount of manipulation which 
the patient experiences at this period. In the beginning 
of the stage there is little change ; but as the reflexes return, 
the respiration may be increased or diminished. As the pa- 
tient suddenly loses the stimulating effect of C0 2 , the res- 
pirations will drop in frequency, but as the pain of the 
stitches is felt, the respirations will again increase. Dis- 
turbances in the rhythm and amplitude are subject to at- 
tacks of retching and vomiting. 

In the second half of recovery: In the second half of 
the stage of recovery, between the complete return of the 
reflexes and the return of consciousness, the rate may drop 
to six or eight respirations a minute. The rhythm may be 
regular or may resemble Cheyne- Stokes. The amplitude 
may be either small or large. Such eases may be ascribed 
to a profound reaction, to morphine or to a reaction which 
follows in the course of excessive rebreathing. One should 
differentiate these two types of cases, as the treatment for 
one would be the worst thing possible for the other. The 
depression of the respiration from the use of morphine will 
usually be associated with a pin-point pupil and will have a 
tendency to persist. Where a reaction to rebreathing is 
the cause, the pupil will be normal or enlarged and the con- 
dition will tend to pass off. When the patient will not 
breathe spontaneously, artificial respiration must be in- 
duced as follows: 

Artificial Respiration. — Artificial respiration is for the 
purpose of intermittently replacing the air in the mouth, 
trachea and bronchi. The nature of this replacement must 
approach the ideal offered by spontaneous respiration. 
The rate, the volume, and the pressure under which fresh 



THE SIGNS OF ANESTHESIA 91 

air finds its way into the lungs are the standards which 
govern artificial respiration. 

Respiration consists of two phases, inspiration and ex- 
piration. We are chiefly concerned with inspiration. Ex- 
piration comes about spontaneously through the natural 
resiliency of the structures involved. 

There are two methods of artificial respiration: (1) 
negative ventilation; (2) positive ventilation. 

Normal respiration brings about negative ventilation. 
The ribs being raised and the diaphragm contracted, the 
cavities containing the lungs are enlarged. Atmospheric 
pressure within the latter quickly fills the partial vacuum 
thus formed. With such normal respiration negative ven- 
tilation is most efficient. 

Where spontaneous respiration has failed, however, 
artificial respiration by negative ventilation can bring 
about only a partial inspiration because the diaphragm has 
ceased to act. The ribs may be raised but the diaphragm 
cannot be lowered as in normal respiration. 

Negative ventilation is exemplified by the well-known 
method of Sylvester, the technic of which is as follows : 

1. The tongue is grasped by sponge or artery forceps 
and pulled well forward. This first manoeuvre is abso- 
lutely essential to insure freedom of the airway. Complete 
extension of the head over the edge of the table should be 
practised, as shown in Figs. 55 and 56. 

2. With the patient lying flat on his back, the head 
well extended, the operator stands at the head, grasps the 
arms just above the elbows and presses them firmly and 
steadily against the sides of the chest ( Fig. 55 ) . After a 
couple of seconds the arms are extended and brought over 
the patient's head. This act by lifting the ribs causes in- 



n ANAESTHESIA 

spiration by negative ventilation (Fig. 56). These two 
movements should be repeated sixteen to eighteen times 
a minute. 

Artificial Respiration by Positive Ventilation. — By 
positive ventilation we endeavor to intermittently distend 
the lungs by air delivered directly into the trachea or into 
the pharynx. At the time of distention (inspiration) the 
chest incidentally expands. We say incidentally because 
the movements of the chest are passive; they are only an 
index of the degree of lung expansion. 

At the time of distention the paralyzed diaphragm 
sinks, being forced downward by the increased intrapul- 
monary pressure. Expiration occurs through the return 
of the diaphragm and the falling of the ribs. 

The most important single factor in positive ventila- 
tion is the pressure at which the air is thrown into the lungs. 
This pressure should not exceed 25 to 30 mm. of mercury. 
If greater pressure is employed rupture of the delicate 
air vesicles may result. Positive ventilation may be brought 
about by intratracheal insufflation. The technic of this 
procedure is identical with that described on page 163 for 
intratracheal anaesthesia, the only difference being that air 
alone is delivered intermittently instead of constantly. This 
is the most reliable method of positive ventilation and may 
be done by an improvised catheter or small tube, to which 
is attached an ordinary foot bellows, and simple pressure 
gauge. 

A pressure gauge may be improvised by putting one 
and one-half inches of mercury in the wash bottle attached 
to the oxygen tank. The short tube is left free, the long 
tube projects 25 mm. (one inch) below the surface of the 
mercury and is connected to the tube which delivers the 



THE SIGNS OF ANESTHESIA 93 

air from the bellows to the patient (see Fig. 57). Any 
pressure in this tube greater than 25 mm. or one inch of 
mercury will escape out of the bottle. If mercury is not 
available, a pitcher or jar of water 15 inches deep will do. 
A tube projecting into this water for a depth of 13 }4 
inches will give the same result since the specific gravity 
of mercury is 13.59. 




Fig. 55. — Sylvester method of artificial respiration, first position. 

Positive ventilation by intrapharyngeal insufflation is 
not quite so efficient. Air delivered into the pharynx es- 
capes in four directions : into the mouth, into the nose, into 
the oesophagus and stomach, and into the trachea. Every 
exit but the tracheal must be shut off. The mouth may be 
closed by a strip of adhesive plaster fastened at one end 
under the chin and at the other to the forehead. Escape 
through the nose is controlled by the presence of the nasal 



94 



ANAESTHESIA 



tubes (Figs. 83 and 86) through which the air is being 
delivered. Accumulation of air in the stomach is prevented 
by placing a heavy weight (twenty pounds) on the abdo- 
men and strapping this in position. The operator may sit 
on the abdomen if a weight is not available. If artificial 
respiration must be carried on during a laparotomy, a 
stomach tube should be passed and left in situ. This will 




Fig. 56. — Sylvester method of artificial respiration, second position. 

dispose of air which may accumulate in the stomach. The 
abdomen being open the operator may make manual press- 
ure on the stomach, thus preventing its distention. 

If oxygen from a low pressure tank (P. 144) is allowed 
to flow into the pharynx of the patient (Page 155) while 
the Sylvester method is being employed, the result is 
remarkable. 

The author has seen a patient who had been dead for 



THE SIGNS OF ANAESTHESIA 



95 



five minutes or more (no heart beat by intrabdominal 
manipulation, no respiratory effort, lividity, corneal reflex 
gone, ocular tension gone, pupils dilated) when subjected 
to artificial respiration with oxygen in the manner des- 
cribed, change from lividity (70 or 80% cyanosis) to a 
bright pink (zero to 10% cyanosis) this color being main- 
tained in the lips and the ears during the manipulation 
and disappearing at their cessation. This phenomenon 



? a 



to 
itienf 




-from 
foot bellows 



Fig. 57. — Simple form of Mercury Manometer. 

continuing for a period of more than a half hour; the 
patient meanwhile showing no respiration or heart beat 
and never recovering. Circulation appeared to be carried 
on by the mechanical act of respiration. 

Among the mechanical devices for the treatment of 
respiratory failure, the best is that of the late Dr. Meltzer, 
which will be found described in detail on Page 357. 

Recapitulation. — Broadly speaking, we may say that 
our chief respiratory difficulties in the stage of induction 
are disturbed rhythm and shallowness. Stoppage of the 
respiration in this stage is due to obstructed respiration 
or acapnia. 



96 



ANAESTHESIA 



In maintenance, disturbances of rhythm and increased 
rate. Stoppage of the respiration in this stage is due to 
too much ether or acapnia. 

In recovery, disturbances of rhythm and reduced rate. 
Stoppage of the respiration in this stage is due to obstruc- 
tion of the respira- 
tion or to the 
untoward effect of 
morphine. 

When the open 
drop method is em- 
ployed, our chief 
difficulty will be de- 
creased amplitude. 
This will retard 
induction, diminish 
our control of main- 
tenance and delay 




Fig. 58. — The Hsemoxometer (oxyhsemoglobinometer,) an 

instrument for the clinical measurement of cyanosis 

(oxygen unsaturation). 



the recovery. 



When the closed 
method is used, we will be annoyed by excessive res- 
piratory efforts and, unless provision is made for con- 
stant small dosage as in the case of the closed drop 
method, we will find a frequent and embarrassing change 
in rhythm. It will also be found that the closed method 
will obscure respiratory sounds, which would be distinctly 
audible with an open mask. 

In order to better appreciate the significance of abnor- 
malities in respiration, it has been suggested that the anaes- 
thetist occasionally try upon himself the rate of rhythm 
and amplitude which the patient exhibits. 



THE SIGNS OF ANAESTHESIA 97 

II. THE COLOR SIGNS. 

In company with the respiration the color is one of the 
signs which become immediately available when anaesthesia 
is induced. As is well known, the blood and in consequence 
the tissues, depend upon the haemoglobin in the red cells 
for their color. The amount of this color is measured by 
the hsemoglobinometer. This instrument, however, meas- 
ures only the amount of the color. It does not measure 
its quality or shade. This hue, or quality of the blood 
ranging from the darkest venous to the brightest arterial 
depends upon the relative amount of oxygen or oxyhaemo 2 
globin which it contains. Arterial blood with all the oxy- 
gen which it can carry (complete saturation) affords one 
extreme. Venous blood with all its oxygen removed 
(complete uncaturation or cyanosis) affords the other 
extreme. 

Heretofore, cyanosis was a relatively indefinite term 
which did not describe. In order to meet this need for a 
clinical measure of cyanosis, the author has devised a 
Hsemoxometer or Oxyha?moglobinometer by means of 
which cyanosis in the mass of circulating blood, in the skin 
and in the mucous membranes may be measured. 

The Hsemoxometer was prepared as follows: 

Specimens of oxylated blood were completely oxygen- 
ated, the resulting color being accurately matched by a 
non-fading ink of a known formula. This color was 
called complete saturation, zero or no cyanosis. The 
same specimen was completely deoxygenated, the result- 
ing color being similarly matched and called complete un- 
saturation, 100% or complete cyanosis. Using these two 



98 ANAESTHESIA 

fixed unchanging extremes, a scale of intervening percent- 
ages has been made. The hsemoglobinometer has been 
checked up by careful quantitative analysis so that it forms 
a positive basic measure of the oxyhemoglobin content of 
the circulating blood. The popular term "cyanosis" and 
the technical term "oxygen unsaturation" may be used 
interchangeably, for example: 20% oxygen unsaturation, 
20% cyanosis. 

The opacity presented by the skin, the finger nails and 
the mucous membrane is being studied and closely dupli- 
cated by the Maunsell System of color notation. 

While the color necessarily depends upon the pulse, 
yet in many instances, it is of more immediate value. The 
color sign is especially useful during the stage of induc- 
tion, when, generally speaking, the pulse may be entirely 
ignored. During the stage of maintenance it is important 
to carry a low percentage of cyanosis. It will be observed 
that in ether anaesthesia even those who have little or no 
color, will, after induction, show a very definite, ever- 
changing tint. This color will, necessarily, be more in 
evidence in the florid, full blooded individual than in the 
septic or ansemic. It will vary from complete oxygen- 
ation, to 40 or 50% cyanosis. What color shall we endea- 
vor to mainain? The best color is the normal color (0 to 
5%), plus the flush which is the physiological effect 
of the ether. The faces, necks and chests of the full 
blooded, dark complexioned individuals are very likely 
to be bright scarlet, fading as the anaesthesia progresses. 
Occasionally, an erythema appears which persists for a 
short time. The ears and the lips of the septic and the 



THE SIGNS OF ANAESTHESIA 99 

ansemic should be pink ; this will often be accompanied by 
a hectic flush of the cheeks. Pallor implies a state of 
acapnia or low alkaline reserve, concomitant with an ab- 
sent or greatly diminished respiration. Incidentally, it 
will be well to remember that the absence or the presence 
of carbon dioxide has nothing to do with the cyanosis. 
Carbon dioxide is present in the blood chiefly as an acid and 
does not enter into chemical union with the haemoglobin. 

Whex the Open Method is Used. — The color is 
entirely satisfactory during induction. As maintenance 
progresses however, the patient is prone to develop 
acapnia from loss of carbon dioxide. More or less pallor 
then appears and persists during the stage of recovery. 
One often finds associated with this loss of color a cold, 
perspiring skin. 

Whex the Closed Method is Used. — During the 
stage of induction with a closed method, using a gas ether 
sequence, the patient while breathing nitrous oxide is prone 
to develop cyanosis which rapidly increases when the air 
is excluded. Limitation of oxygen during the period of 
excitement is thought to increase the potency of the ether 
and to hasten the onset of maintenance. The patient 
should never be permitted to be more than briefly cyan- 
osed. Marked continued cyanosis will be followed not 
only by delayed induction but by an increase in blood 
pressure which is very likely to be harmful. When ster- 
tor has come on, and while the stage of rigidity persists, 
air or oxygen should be freely admitted and rebreathing 
encouraged. Persistent cyanosis in the presence of free 
breathing with no obstruction in the upper airway, would 



100 ANAESTHESIA 

suggest an asthmatic or pneumonic process, capillary sta- 
sis or poisoning. In such a case, oxygen should be given 
continuously by means of the closed method. 

During maintenance a high color is commonly asso- 
ciated with a warm skin and a profuse perspiration. Such 
patients should be carefully guarded against draughts, 
which, by evaporating the surface moisture, will rapidly 
reduce the patient's temperature. When there is marked 
hemorrhage, it is particularly important that a good color 
of the mucous membranes be maintained. Cyanosis at this 
time means more to a patient than it does when there is a 
large amount of circulating blood. In this condition, the 
cheeks and ears become waxy in appearance. Oxygen 
must be used freely in these patients to insure a good color. 

In the stage of maintenance, when the closed method 
is used, the control of the color is either not so good, or 
better than where the open method is employed. This 
will depend upon the ease with which atmospheric oxygen 
or pure oxygen may be admitted to the apparatus. If 
the rebreathing is hampered by gauze in too large quan- 
tities or wrongly placed it will be found difficult to hold a 
good color. If the rebreathing is entirely free the stimu- 
lation from the carbon dioxide by inducing a deeper 
respiration, will also afford a means of more easily 
oxygenating a patient. 

The surgeon will sometimes remind us of the color by 
remarking that the blood is very dark at the site of the 
operation. This sign may also be quite marked even when 
the color of the lips and ears seems satisfactory unless 
checked up by the hsemoxometer. 



THE SIGNS OF ANAESTHESIA 101 

In the Stage of Recovery When the Closed Method 
is Used. — During this stage we may find a tendency 
to pallor. This, however, will not be so marked as 
when the open method has been used. The presence or 
the absence of color depends upon the depth of the respira- 
tion. A strong man breathing deeply may have a normal 
color. The same man scarcely breathing may appear 
pallid. 

Jaundice. — We often meet patients who are intensely 
jaundiced. It is quite difficult to maintain a satisfactory 
color in this case. The color of the mucous membrane 
is our best guide. A slight cyanosis will often pass by 
unnoticed. This cyanosis, being a sign of deeper trouble, 
will often interfere with the smoothness of the anaesthetic. 
The color of the blood at the site of the wound will often 
be our best guide as to the proper oxygenation. 

Negroes. — This race shows a very unsatisfactory color. 
Here again, we must depend upon the color of the lips and 
the hue of the blood at the site of the wound. Pallor is 
sometimes evident as a clayish appearance of the skin 
which may feel chilled and be bathed in cold perspiration. 
Nitrous oxide and oxygen should not be used upon colored 
patients unless positive indications exist, since this type 
of anaesthesia depends more upon the color sign than upon 
any other. 

Briefly reviewing we find that the color and the respira- 
tion go hand in hand. The color may be taken as an index 
of the efficiency of the respiration and will serve to indi- 
cate the necessitv or the inadvisability of interference. A 






102 ANESTHESIA 

good color is a guarantee of the safety of the patient at 
the particular moment under consideration. The color, 
while dependent upon the condition of the pulse, will, 
nevertheless, warn the anaesthetist of danger before a per- 
ceptible change can be felt in the rate or quality of the latter. 
Blood pressure readings taken during the course of 
the operation are extremely valuable in detecting the onset 
of shock. Under ordinary conditions, however, this addi- 
tional technique is not practical outside of a large clinic. 
High color or cyanosis is often associated with a profuse 
perspiration and a warm skin. Hemorrhage and shock 
become evident in pallor, and a cold perspiration which 
breaks out on the forehead. Cyanosis must never be 
looked upon with complacency. Pallor concentrates the 
attention upon the pulse and blood pressure which now 
become our best guides as to the condition of the patient 
and the most reliable index as to his need of stimulation. 

III. THE MUSCULAR SIGNS 
We have considered normal muscular tone, rigidity and 
relaxation. We have tried to emphasize the causes and the 
control of each. The signs exhibited by the muscular 
system depend for their value upon a variable degree of 
relaxation. Three signs may be easily observed: The 
masseteric, the lid and the diaphragmatic. 

The Masseteric Sign consists of a relaxation of the 
muscles, which control the lower jaw, permitting the 
mouth to be opened and closed without resistance. When 
one is in doubt as to the general relaxation which obtains 
the presence of relaxation of the lower jaw will almost 



THE SIGNS OF ANAESTHESIA 103 

always settle the question. Occasionally, however, even 
when complete relaxation is present elsewhere, respiratory 
disturbances will cause incomplete freedom of the lower 
jaw, when one attempts to elicit this sign. During the 
period of excitement, rigidity and early relaxation, this 
sign is of course negative. If a " low " level of mainte- 
nance is held, this sign may not show itself in its fulness 
throughout the course of the anaesthesia. During a stage 
of maintenance suitable for abdominal relaxation, however, 
it is almost invariably present. As recovery proceeds one 
will note the relaxation pass off, the normal tone and 
rigidity of the masseters taking its place. This disappear- 
ance of the relaxation during the stage of maintenance is 
one of the early indications that the patient is recovering 
and must be either carefully watched or carried along at a 
higher level. 

Where short operations are done for intra-oral work 
and an incomplete anaesthesia is all that is required, the 
anaesthetist should begin his induction with a mouth prop 
or cork between the patient's teeth, for with such a type 
of anaesthesia, rigidity of the masseters is the rule. 

Relaxation of the Upper Eyelid. — During normal 
sleep the eyelids, owing to the tone of the orbicularis palpe- 
brarum, remain closed. In the late part of excitement 
and through the period of rigidity, one will find that if the 
eyelid is lifted and then released, it will fall back into place 
with more or less snap. Later it will remain open. 

The lid sign is present when the eyelids on being sepa- 
rated remain separated. This sign should be taken on each 
side and the most inactive lid taken as the standard. In the 
later periods of induction, when stertor has come on and 
one is anxious to determine the exact condition of the pa- 



104 



ANAESTHESIA 












tient, this sign with the masseteric sign will be found very 
valuable. The lid reflex is usually described as an eye sign. 
We feel, however, that it relates more directly to the mus- 
cular system. Furthermore the signs of true muscular 
relaxation during the stage of induction are none too many 
and may well be augmented by this addition. 





-Diagram showing normal move- 
ment of diaphragm and abdominal 
wall during inspiration. 



Fig. 60. — Diagram showing movements of 

diaphragm and the abdominal wall during 

inspiration, just before a fatal issue. 



The Diaphragmatic Sign. — This sign deals with the 
tonus of the diaphragm. It is of value when one is obliged 
to carry a high level of maintenance, as is sometimes the 
case in upper abdominal operations. We base our deter- 
minations of the relaxation of the diaphragm upon the 
character of the abdominal respirations. Normally, when 



THE SIGNS OF ANAESTHESIA 105 

inspiration takes place, the diaphragm moves downward 
upon the abdominal viscera and causes a distention of the 
abdomen, which raises the abdominal wall (Fig. 59) . The 
amount of the abdominal movement is greatest during the 
period of excitement when the movements of the diaphragm 
are excessive. As anaesthesia progresses, these move- 
ments become less, but the abdomen still swells upon in- 
spiration. If the level of the anaesthesia be excessively 
raised, however, the diaphragm relaxes, and the abdomen, 
instead of being distended, will sink during inspiration 
( Fig. 60 ) . This sinking in of the abdomen during inspira- 
tion is one of the gravest danger signs and indicates that 
anaesthesia has been pushed beyond its legitimate limit. 
Preceding this paralysis the breathing will become almost 
entirely thoracic. These are the cases who have absolute 
relaxation, absent corneal reflex and a dilated pupil, and 
whose breathing is rapid and shallow. Occasionally we are 
obliged to " go the limit," but we should at least understand 
what constitutes " the limit." 

Our first concern then is to secure relaxation of the 
eyelid and lower jaw. When we have passed into the 
stage of maintenance and we know that the patient is 
deeply anaesthetized, we should narrowly observe the move- 
ments of the abdomen during inspiration until the stage of 
recovery has begun. 

IV. THE EYE SIGNS 

The eye signs consist of three groups, the lid signs the 
globe signs and the pupillary signs. 

The Lid Reflexes consist of reflex responses to irrita- 
tion of the sensitive conjunctiva and cornea. These signs 



106 ANESTHESIA 

are as follows: The Conjunctivo-Palpebral Reflex, the 
Corneal Reflex and Parsons 's Sign. 

The Conjunctivo-Palpebral Reflex is the reflex which 
causes the eyelid to close when the tip of the finger, in sepa- 
rating the lids, gently brushes over the margin of the upper 
lid. This reflex must be differentiated from the lid reflex, 
which has been described under the muscular signs, and 
is due to the tone or the elasticity of the muscle which 
moves the lid. 

The Corneal Reflex. — This reflex is without doubt the 
most valuable eye sign which we have. It is elicited as 
follows : Standing behind and above the patient, the opera- 
tor gently bathes the orbital conjunctiva by moving the 
upper lid over it several times. He then separates the lids 
with his index finger. When the lids have been slightly 
separated, the index finger is removed and the pulp of the 
middle finger, moistened with vaseline, is very gently 
caused to brush over the centre of the cornea. The degree 
of activity, with which the eyelid then closes, constitutes 
one of the most unvarying signs of the depth of the anaes- 
thesia. The operation is concluded by again washing over 
the orbit by the upper lid. This particular sign and its 
elicitation have been the subject of much adverse criticism. 
It has appeared to many a somewhat barbarous practice. 
The author once held this view. Needless to say it is not 
a sign to be used thoughtlessly or roughly. It is a sign 
which one uses to corroborate other signs. We have yet to 
see any trouble arising from its use. Compare this very 
mild form of irritation to that too often produced by a 
piece of gauze placed over the eyes, to protect them during 
the course of the anaesthesia. The lid reflex having been 
lost, the bare gauze rubs constantly and harshly against 



THE SIGNS OF ANAESTHESIA 107 

the sensitive cornea. The result is a varying degree of 
conjunctivitis or worse. We cannot hide our heads like 
the ostrich and say that there is no harm because it is 
not visible. 

Some advise that the eye signs, or at least the corneal 
reflex be disregarded. This may be done if one is not 
particular as to the exact condition of the patient at 
any given time. Such a course would appear analogous 
to one objecting to the taking of a blood count because of 
the possible danger of tetanus from infection, caused by 
the pin prick. The corneal reflex is without doubt the best 
corroborative sign which we have and, properly taken, is 
free from danger or annoyance to the patient. 

During the period of excitement and rigidity, the corneal 
reflex is snappy; as relaxation comes on the sharpness of 
the reflex gradually decreases. When maintenance has been 
entered into, the reflex has either become quite sluggish or 
is absent. The reappearance of the corneal reflex and its 
variable activity during the stage of maintenance will give 
one a most satisfactory idea as to the exact depth of the 
anaesthesia. When the stage of maintenance is carried at 
such a high level that the corneal reflex has disappeared, 
its prompt return in the first stage of recovery will always 
prove a great comfort. Generally speaking we may sav 
that a dangerous level of maintenance and an active corneal 
reflex do not coexist. One should not take this sign re- 
peatedly on the same eye, as the sensitiveness will rapidly 
diminish. The most active of the two eyes should be taken 
as the standard. The use of morphine will frequently dull 
this reflex. When N 2 and O are used without ether, one 
will usually find a snappy reflex during an entirely tran- 
quil stage of maintenance. Unexpected variations in this 



108 ANAESTHESIA 

reflex will be found in little children and very sick patients. 
Again we would urge that the individual patient be caused 
to form his own index of activity, and while this sign is 
most valuable per se, yet it should be supported and sus- 
tained by other signs. 

Parsons 's Sign. — This consists of a retraction of the 
lower lid towards the internal canthus, when the carti- 
laginous rim of the upper lid is pressed against the cornea 
immediately over the pupil. The degree to which the re- 
traction of the lower lid takes place indicates the depth of 
the anaesthesia. 

The Orbital Signs. — The presence or absence of move- 
ments of the eyeball during anaesthesia will often be found 
of value. As a sign purposeful movements will usually 
be recognized by the peculiar look of animation and expres- 
sion. When these intelligent, calculating eyes look at us, 
we are likely to feel apologetic and to cover them over with 
gauze or a towel. When consciousness is lost, however, and 
the period of excitement or rigidity is well developed, we 
find that the eyeballs are fixed or that there is a slow move- 
ment from side to side. Movements of the eyeball from 
side to side are almost always a sign of light anaesthesia. 
We will be very likely to find such movements in the period 
of excitement, rigidity and early relaxation. During ordi- 
nary maintenance movement is absent, but it may occur 
when a very low level is carried. During the stage of 
recovery this sign will usually be found strongly in evi- 
dence and a precursor of approaching consciousness. Dur- 
ing the stage of maintenance, when N 2 and O are the 
anaesthetic, the eyes will often be found looking fixedly 
downward. When ether is used, they are usually fixed 
centrally. 



THE SIGNS OF ANESTHESIA 109 

Generally speaking, we may say that when the eyes are 
stationary, looking either downward or straight forward, 
loss of consciousness is certain, and usually induction is 
nearing conclusion, or maintenance has been entered upon. 

The Pupillary Signs. — Let us first consider briefly the 
physiology of the pupillary changes which may appear. 
We must explain three reactions: Dilation of the pupil; 
contraction of the pupil, and the reaction to light. 



\ 



flfs ^*<SZ*-e*fGltaryJrerre9 



Superior Cerr/ca/ 



<janpZi 



ton 



d 





•■Difatpr 
Optic /terre. W I ftapztfa* 



'Jpbzneter 



Pupi/tae 



•SympaMetec 



Fig. 61. — Diagram showing enervation of the dilator and sphincter pupillse. Modified from 

Howell's physiology. 

Fig. 61 will show clearly the mechanism with which 
we have to deal. 

Two sets of muscles. — The dilator pupillse and the 
sphincter pupillse. 

Two nervous systems — The sympathetic, which sup- 
plies the long ciliary nerves to the dilators, and the central, 
which supplies the short ciliary nerves to the sphincter 
muscles. 

Two general conditions, which effect this mechanism — 
Stimulation and paralysis. 



110 ANAESTHESIA 

Stimulation. — The pupil dilates when the sympathetic 
system is stimulated. The pupil contracts when the cen- 
tral system is stimulated by light (afferent impulses travel 
by retinae and optic nerve; efferent by third cranial and 
short ciliary). 

Paralysis. — When the sympathetic system is paralyzed, 
the pupil contracts by virtue of the tone of the sphincters, 
aided by the engorgement of the ciliary blood-vessels. 
When the central system is paralyzed, the pupil dilates by 
virtue of the elasticity of the elastic fibres of the pupil and 
by the emptying of the ciliary blood-vessels, which permit 
the lens to bulge forward. 

The understanding of these simple mechanics will en- 
able one to anticipate the signs which may be expected in 
the various stages of anaesthesia. 

The Pupillary Signs in Induction, Maintenance 
and Recovery 

Induction. — During the periods of excitement and rig- 
idity, the sympathetic system is everywhere stimulated, 
consequently the pupils at this time are usually dilated. 
The amount of this dilatation will depend upon the excita- 
bility of the sympathetic system at the time under con- 
sideration. If there is a greatly reduced irritability, as 
where morphine has been given before operation, this dila- 
tation may be very brief and occasionally absent altogether. 
As the period of relaxation comes on, the sympathetic sys- 
tem will become paralyzed and the pupil will contract. 
The central system being intact, however, the reflex to 
light will remain. 

Maintenance. — The exact condition of the pupil in the 
stage of maintenance will vary according to the degree to 



THE SIGNS OF ANAESTHESIA 111 

which the sympathetic system is anaesthetized. If only 
partly, there will be moderate transient dilatation upon 
pain stimuli. If deeply, the pupil will be smaller than 
normal and show little or no reaction to sympathetic 
stimuli. Movements of the margin of the pupil, more or 
less rhythmical in character, may show themselves when 
pelvic or gall-bladder stimuli are applied. When the pupil 
is contracted, the reflex to light will vary with the irrita- 
bility of the central nervous system or the level of mainte- 
nance. If the anaesthesia is now pushed, the pupil will dilate 
by virtue of the paralysis of the central nervous system. 
Since the light reflex depends upon the integrity of the same, 
this reflex will likewise be lost. The corneal reflex will 
have disappeared and other signs of complete anaesthesia 
will manifest themselves. However clear this condition 
may appear upon theoretical consideration, it is often 
rather puzzling, especially to the beginner, to determine 
whether a dilated pupil is a sympathetic dilatation of light 
anaesthesia or a paralysis of profound anaesthesia. The fol- 
lowing test should always be made where doubt exists : 

Stop the anaesthetic completely and give air. If, after 
a few moments, the pupil contracts (from shallowness of 
the anaesthesia ) , then the dilatation was that of profound 
ancesthesia or dilatation of paralysis. The eye in this case 
is usually dry and lusterless from an inhibited lacrimation. 

If, on the other hand, the pupil remains unchanged in 
the face of shallower anaesthesia, the dilatation was caused 
by sympathetic stimulation and took place because the 
anaesthesia was incomplete. The eye in this case is usually 
moist, the lacrimation being abundant. 

Occasionally one finds a patient who is morphinized, 
or who, for some unknown reason, loses his corneal reflex 



112 ANESTHESIA 

early, having a persistently dilated pupil, which cannot be 
reconciled with other signs. In such a case it is always 
wiser to give the patient the benefit of the doubt and to 
permit him to drop to a lower level of maintenance or to 
" come out." 

If moderate dilatation is present with an active light 
reflex, we may conclude that this dilatation is not the dila- 
tation of paralysis, but that the patient is safe. The most 
satisfactory condition of the pupil during the stage of 
maintenance is when it is moderately contracted and re- 
sponds to light. 

Recovery. — During the stage of recovery, the condition 
of the pupil will again vary, depending upon the respective 
action of the various stimuli applied to the central or sym- 
pathetic system. As a rule the action of the latter is more 
pronounced, and consequently the pupil usually dilates. 
This is particularly true when the patient is about to vomit. 
Where morphine has been used and the recovery is entirely 
tranquil, the pupil may become pinpoint. The light reflex 
is present and becomes more and more active as the patient 
recovers. 

In recapitulating we find that the eye signs are divided 
into the lid, the orbital and the pupillary signs. The pres- 
ence of the conjunctivo-palpebral reflexes means a shallow 
anaesthesia, its absence a moderate height. The presence 
of the corneal reflex depends upon its activity. Its absence 
almost invariably indicates a complete anaesthesia. When 
the eyeballs move the patient is light. When they are 
fixed, either looking forward or downward, the patient has 
certainly lost consciousness, and is probably well anaes- 
thetized. A dilated pupil with moist eyeball, which does 
not contract when the anaesthesia is withdrawn, with an 



THE SIGNS OF ANESTHESIA 113 

active corneal and light reflex, means shallow anaesthesia. 
A dilated pupil with a lusterless eyeball, with an absent 
light reflex and corneal reflex, which contracts when the 
anaesthetic is withdrawn, means profound anaesthesia, or a 
high level of maintenance. A contracted pupil with an 
active light reflex is a safe sign. 

A contracted pupil without light reflex indicates mor- 
phinism and may suddenly be followed by a marked para- 
lytic dilatation. The total absence of the light reflex 
independent of the size of the pupil implies interference 
with the central nervous system, usually a profound anaes- 
thesia. By this we mean the reaction to a strong light, not 
the ordinary daylight. 

From the foregoing it is therefore clear that one ex- 
amines the orbit for motion, the pupil for size and for light, 
and lastly the cornea for lid activity. 

V. THE PULSE SIGNS 

The pulse is an index of the operative condition of the 
patient. One should note its rate, its rhythm and, most 
important, its volume. During the period of excitement 
and rigidity the pulse will be of little value as a sign. 
As relaxation becomes complete, however, and the stage of 
maintenance is begun, we should observe it carefully. 
When the radial artery is not accessible, as it seldom is, then 
we should locate the temporal on the side most convenient, 
palpating it with the pulp of the middle finger. If we 
palpate the same artery in the same location with the same 
finger throughout the anaesthesia, we will form concepts of 
small variations in quality, which would otherwise be passed 
over. 

Rhythm is normally constant. The skipping of beats, 
8 



114 ANESTHESIA 

when occurring frequently, is a danger signal and should 
be reported to the surgeon. This is more particularly true 
when the pulse has been regular during the early stages 
of the operation. 

The rate and volume must be considered together. The 
pulse rate will often soar from pain stimuli or some deep 
reflex. Certain types of cases such as, for example, exoph- 
thalmic goitre, will have an exceedingly rapid pulse. If the 
volume is maintained there is not much ground for anxiety ; 
if, however, the volume falls through hemorrhage or shock, 
the operator must be informed. Generally speaking, the 
surgeon should be notified when the patient consistently 
runs a pulse of 140 or over. If, in addition to an increase 
in rate, the pulse becomes small and rather difficult to pal- 
pate, preparation should be made for the administration 
of saline solution. This is the first and best treatment for 
such conditions. One of the easiest ways to give saline is 
to pour it directly into the abdominal cavity. The most 
direct and effective method, however, is to give an intra- 
venous inj ection into the median basilic vein of either fore- 
arm ( Fig. 62 and 63 ) ; the technic of this is as follows : 

(a) Tie a tourniquet (bandage) about the arm above 
the elbow; (b) paint the bend of the elbow with iodine; (c) 
find the vein if possible. If it cannot be found, cut down 
to where it should be. When it is found, dissect it free for 
about an inch. 

Tie a ligature below (distal) and place an untied liga- 
ture above (proximal) ; nick the vein with a scissors. See 
that the saline runs freely through the cannula and that 
the latter is free from bubbles. With the saline flowing, 
insert the cannula into the proximal end of the vein ; tie in 
place with one knot. With the saline elevated about four 



THE SIGNS OF ANAESTHESIA 



115 



feet above the vein and the tourniquet about the arm re- 
moved, let the solution flow slowly. The amount given 
should vary with the needs of the patient; from 500 to 1500 




Fig. 62. — Intravenous administration of saline; nicking vein. (Annals of Surgery.) 

cc. will usually be found sufficient. If too much fluid is 
admitted there will be increased pressure upon the right 
heart, which may suddenly dilate. The volume of the pulse 
should be watched, and when its character has improved 



^ 



116 



ANESTHESIA 




Fig. 63. — Intravenous administration of saline; cannula tied in proximal end of 
vein. (Annals of Surgery.) 



ii 



klL • - — . 



THE SIGNS OF ANAESTHESIA 117 

sufficiently, the flow should be stopped. The cannula is 
withdrawn and the vein securely tied. The skin is then 
sewed with silk or linen and a sterile bandage applied. 
Needless to say this operation should be completed with 
despatch. If the pulse has become very small, rapid, or 
imperceptible before the saline is given, it is well to give 
immediately strychnine gr. 1/30 or camphor in oil gr. 2. 

While this treatment is taking place, the patient should 
be as as lightly anaesthetized as possible. The indications 
here are to give enough anaesthetic, and only enough, to keep 
him quiet. Oxygen may be resorted to with advantage and 
rebreathing is beneficial. Cases which receive rebreathing 
with oxygen will be much better off than those who are held 
by the open drop method. The author has frequently 
carried pulseless patients for more than an hour rebreath- 
ing oxygen and just enough NT 2 to control undesirable 
movement. The full retarded pulse following a saline is 
often misleading, as it is artificial and will soon lose its 
quality. It behooves one to get the patient to bed as soon as 
possible. If the operative procedure is such that the patient 
cannot be moved, and if the pulse loses its quality and once 
more becomes rapid, the saline may be repeated in the other 
arm. The condition of such a patient is desperate and his 
response to strychnine and camphor will be unsatisfactory. 

Where it is inadvisable or impossible to give an intra- 
venous inj ection, the fluid may be given by hypodermocly- 
sis, under the loose tissues of the breast ( Fig. 64 ) , which 
method is very satisfactory. The Trendelenburg position 
will improve the pulse ; the opposite will weaken it. 

Sudden stoppage of the heart is fortunately rare with 
ether ; such a condition not responding to artificial respira- 
tion may be handled by the method described by Abrams. 



118 



ANAESTHESIA 




Fig. 64. — Hypodermoclysis. 



THE SIGNS OF ANAESTHESIA 119 

This is called Kuatzu or the Japanese method of restoring 
life, and is a definite method of resuscitation used by 
jiu-jitsu adepts. The patient is placed in the prone 
position with arms extended sideways; the operator with 
his wrist lands severely on the seventh cervical vertebra 
with the regularity of a carpenter wielding a hammer. 
This stimulation is thought to act by overcoming the vagus 
inhibition responsible for the cessation of the heart's action. 
The hypodermic injection of 1 100 gr. of atropine 
directly in the heart has been suggested and found valuable 
in some cases. Direct massage of the heart, when the 
abdomen is open, will also prove beneficial at times. 



CHAPTER IV 

ETHER ANAESTHESIA 

GENERAL CONSIDERATIONS 

Ether, sulphuric ether, ethyl oxide or vinous ether is 
a very volatile fluid possessed of a suffocating odor and a 
bitter taste. It is colorless, about two and one half times as 
heavy as air and boils at body temperature. Ether is very 
inflammable and should be cautiously employed in the 
presence of an open flame, red-hot cautery and the like. 
Ether vapor, when allowed to escape from a container, falls 
until it comes in contact with the floor, operating table or 
body of the patient. It then travels in a thin layer close 
to the surface with which it is in contact until it is dissipated 
in the air. A flame or hot cautery which is brought within 
two inches of such a surface will cause the ether to burst 
into flame. This may happen in the cauterization of 
hemorrhoids for example. The smoother the surface along 
which the ether travels the more likely it is to retain its 
concentration and ignite. Water has practically no effect 
on burning ether. If carelessly applied it may scatter the 
fire thereby increasing the danger. Ether-soaked gauze 
or free ether which has caught fire should be carefully and 
systematically smothered by the use of blankets, towels, 
etc., beginning at the patient's face. 

Ether is commonly prepared as follows : Ethyl alcohol 
reacts with sulphuric acid to form ethyl sulphuric acid and 
water. In the presence of an excess of alcohol, ether is 
formed and sulphuric acid is reformed as a residue. This 
is known as the continuous etherification process. Ether, 
120 



ETHER ANAESTHESIA 121 

which has been exposed to air and light, should not be used 
for anaesthesia, as the irritation of products formed by oxi- 
dation may prove injurious to the patient. Ether is now 
manufactured by a special process in which the active 
anaesthetic element, ethelene gas, is retained and the irritat- 
ing by-products, aldehydes, etc., are rejected. This puri- 
fied ether is said to be less irritating, but has also been found 
to be less effective. 

A brief consideration of the discovery of ether will be 
found in the Introduction. The various methods of admin- 
istering ether have been taken up in Chapter IV! The 
signs of ether anaesthesia are discussed in Chapter III. 
A classification of the stages of ether anaesthesia has been 
suggested in Chapters I and II. The post-operative treat- 
ment of a case anaesthetized by ether will be found in 
Chapter XV, page 285. 

THE ADMINISTRATION OF ETHER 

Ether may be administered by two methods, by Inhala- 
tion or by Insufflation. 

Inhalation anaesthesia consists of substituting ether 
vapor for the air which the patient normally breathes. This 
vapor may be presented at the patient's lips, oral inhala- 
tion, in the pharynx (by means of a tube) , intrapharyngeal 
inhalation, or in the trachea (by means of a tube) intra- 
tracheal inhalation. 

Insufflation anaesthesia consists of blowing ether vapor 
into the patient's respiratory tract. If blown into the 
mouth the method is spoken of as oral insufflation, if into 
the pharynx, intrapharyngeal insufflation, if into the 
trachea, intratracheal insufflation. 



122 ANESTHESIA 

The inhalation method is the simpler method requir- 
ing the least apparatus. It is the method of choice for the 
stage of induction in every case and is ordinarily employed 
throughout a complete anaesthesia. 

The insufflation method implies the use of compli- 
cated apparatus — for example, the Connell ansesthe- 
tometer in order to produce the very best results. It is 
resorted to only after induction by inhalation. It is 
the ideal method for operations about the head, neck 
and thorax. 

INHALATION METHODS 

Oral Inhalation 

By oral inhalation we mean the substitution of ether 
vapor for the atmosphere which the patient ordinarily 
breathes. (See page 9.) 

This ether vapor may be presented to the patient in a 
great variety of ways. Anything from a gauze handker- 
chief to an expensive nickel-plated apparatus will accom- 
plish the desired result. While we may in an emergency 
get along with a handkerchief, we do not do so from choice, 
but from necessity, as such a method is least efficient and 
most wasteful. 

We recognize two methods of administering ether by 
the method of oral inhalation: 

1. The liquid method. 

2. The vapor method. 

By the liquid method we mean that method in which 
we present liquid ether to the patient upon a medium suit- 
able for its speedy evaporation by the respiration. In 



ETHER ANESTHESIA 123 

this method we depend largely upon the patient to vapor- 
ize the ether. 

By the vapor method we mean that method in which 
the ether is presented to the patient already vaporized. In 
this method the patient's respiration has nothing to do with 
the amount of the ether vaporized. 

The liquid method is best exemplified by the well- 
known drop method. There are three distinct types of 
drop method; Open, Semi-open and Closed, 



f /*\\ 




Fig. 65 — Yankauer-Gwathmey Drop and Vapor Mask. 

The Open Drop Method 

Apparatus. — The essential elements of the apparatus 
are as follows : 

(a) A wire skeleton face piece of substantial construc- 
tion, having a smooth surface for contact with the pa- 
tient's face; (b) covering for the face piece, consisting of 
stockinet bandage or gauze; (c) provision for the supply 
of ether in large, clean drops. 

The Face Piece. — One of the most widely used and 
satisfactory drop masks is that of the Yankauer pattern 
(Fig. 65). 



124 ANESTHESIA 

This fits the face well, presents a smooth surface in 
contact with the skin and is substantially built. 

The Covering. — One of the best materials for an open 
drop evaporation surface is that afforded by stockinet 
bandage. The spring ring, which holds the covering, 
is slipped into a six-inch section of the bandage and 
forced down over the wire frame. Stockinet bandage, 
being more closely woven than gauze, has been found to 
give a more satisfactory evaporating surface. When 
gauze is used, between ten and twelve thicknesses should 
be employed. 

The Drop Bottle. — To obtain the best results one 
should have a device which will give large drops, the 
rapidity of which may be varied at will. 

We speak of clean drops in contradistinction to the 
drizzle which one will obtain from a frayed bit of gauze. 
The anaesthesia resulting from such a drizzle or spray 
method is not nearly as smooth as that obtainable by a 
clean drop. The best drop bottle is prepared as follows 
(Fig. 66): 

Cut the lead cap neatly out of the ether can. Take the 
ether can cork and cut two deep grooves in the sides. In 
one of the grooves place a little wick of cotton (not gauze) ; 
leave the other groove free for the admission of air. Place 
the cork with the cotton wick in the can ; allow the wick to 
become soaked with ether, which will drizzle off the frayed 
end. With a pair of scissors, cut the wet wick so that the 
end is square instead of frayed. A large, clean drop, whose 
rapidity is easily controlled, is then obtained. An emer- 
gency drop bottle may be provided by making a single 
pinhole in the centre of the lead cap in a can of ether, which 



2 § 

B £5 



a ^ 



re ^ 



. . o 



o w 

§1 



■<5 

o ** 




ETHER ANAESTHESIA 125 

has not been opened. If the can is now grasped in the 
palm of the hand, the rise in temperature resulting will 
cause the ether to spray out when the can is inverted. A 
drop may then be secured by controlling the spray with 
the finger tip. 

The Administration. — When the open drop method is 
employed, ether, as a rule, is the sole anaesthetic employed. 
One may sometimes render the induction more pleasant 
for the patient by dropping upon the mask a little essence 
of orange, wintergreen or some pungent essential oil, 
before the ether is given. This occasionally serves to mask 
the disagreeable odor. The trick of a smooth induction, 
however, consists in two things: First, in causing the pa- 
tient to breathe somewhat more frequently and deeply than 
normal. Secondly, in the control of the drop so that there 
will be no spasm of the respiration. One of the best 
methods of controlling the respiration is to ask the patient 
to count slowly and loudly. This requires a certain atten- 
tion and decidedly increases the tidal volume. In addition 
to this, the patient will give evidences of disturbed cere- 
bration, which will indicate the progress of the induction. 
Most patients cannot count slowly and loudly for more 
than one hundred. We increase the drop as rapidly as 
we can and " let up " if the patient catches his breath. If 
this method is pursued, the patient will rapidly develop 
a tolerance, and by the time he has ceased to count he will 
be accepting without spasm an amount of ether which 
almost or entirely saturates the mask. When such an in- 
duction is brought about, the rule is — no excitement oc- 
curs, rigidity is slight and transient, and relaxation comes 
on slowly but completely. The respirations become ster- 
torous, the lid reflex disappears, the jaw relaxes, the eye- 



126 ANAESTHESIA 

balls become fixed, the pupils contract and the corneal 
reflex becomes sluggish, indicating the onset of the stage of 
maintenance. 

Maintenance is best controlled by a constant drop, 
which may be increased or diminished according to a de- 
mand for a high or low level of anaesthesia. If the anaes- 
thetist becomes weary or loses interest during this stage, 
he will very likely change the drop into a spray or pour 
method. This will surely result in an uneven anaesthesia. 
The best results can only be had by employing a constant 
drop. As maintenance progresses, the color will fade, the 
patient will lose surface temperature and the respirations 
will become quite shallow from excessive ventilation. 
Since little ether is lost, little will be needed to hold a con* 
stant level of maintenance. In some cases relaxation wiE 
be difficult to secure ; but in cases where it has become com- 
plete, it will have a tendency to persist. The eye signs 
will respond to an increase or decrease of the rapidity 
of the drop, but they are usually quite constant, fixed balls, 
contracted pupils, absent lid reflexes and sluggish corneal 
reflexes being the rule. 

Since the anaesthesia is under nice control, the stage of 
recovery may be begun earlier. The patient is usually 
brought to the point of vomiting before leaving the table. 
The shallow respirations, however, tend to retard the re- 
turn of the reflexes and the return of consciousness. 

The advantages of the open drop method are as follows : 

1. The simplest apparatus is required. 

2. Perfect oxygenation is obtained. 

3. It is fool proof. 

4. Even anaesthesia, easily controlled in suitable cases. 

5. The best method for inducing anaesthesia when ether 
alone is used. 



. i .- 



ETHER ANAESTHESIA 127 

6. The best method for maintaining anaesthesia in 
young children, when the vapor method is not available. 

The disadvantages of the open drop method are as 
follows : 

1. Certain subjects, as vigorous young people and alco- 
holics, cannot be controlled by this method. 

2. It is extremely wasteful of ether. 

3. The anaesthetist becomes literally soaked by the 
ether forced into the atmosphere by the exhalations. 

4. The method is frequently attended by acapnia and 
shock, through the excessive loss of C0 2 . (See page 299.) 

5. The patient easily loses bodily heat. 

6. Induction is always prolonged and never as pleas- 
ant as when N 2 is used. 

7. It is unsuitable where morphine has been used as a 
preliminary medication. 

The Semi-Open Drop Method 

The semi-open drop method is nothing more than the 
open method so modified that the communication with the 
outside air is restricted and a certain amount of rebreath- 
ing thereby induced. 

When this method is employed, the drop method, 
strictly speaking, is not used as consistently as in the open 
method. The necessity for concentrated ether which this 
method usually implies calls for a spray or pour method. 
The open drop method can easily be modified into the semi- 
open method by the use of towels or a rubber dam. 

By the open drop method and the semi-open drop 
method, one is in a position to handle every case suitable 
for oral insufflation. Any patient from a baby to a two- 
hundred-pound alcoholic may be controlled by the use of 



128 



ANAESTHESIA 



these two methods. This does not mean that one can thus 
obtain the best results, but that in an emergency we can 
anaesthetize any patient who will respond to ether anaes- 
thesia, if we are given time enough and sufficient ether. 

Apparatus. — 1. The open drop mask covered with at 
least twelve layers of gauze. 




Fig. 67. — Ether by the semi-open drop method. First position. First towel in place over the eyes. 

2. Three small towels or a piece of rubber dam 6 inches 
by 12 inches with a 1-inch hole in the centre. 

3. A bottle which will permit of a spray or a small 
stream of ether. 

The Anesthesia. — A folded towel is placed over the 
eyes (Fig. 67). Anaesthesia is induced precisely as with 
the open drop method. When the patient has lost con- 
sciousness, as will be shown by his inability to count intelli- 
gently, the second towel folded lengthwise is placed over 
the upper third of the mask (Fig. 68), the ends being 



V 





Fig. 68. — Ether by the semi-open drop method. Second position. Second towel in place 
covering upper third of mask. 





fli _i MH 



--. 



Fig. 69. — Ether by the semi-open drop Fig. 70. — Ether by the semi-open drop 

method. Third position. Third towel in method. Fourth position. The free end of 
place covering lower third of mask. the third towel is being laid over the exposed 

third of the mask. 




Fig. 71. — Ether by the semi-open drop method. A piece of rubber dam with a one-inch hole 
being used in place of towels. 



ETHER ANAESTHESIA 129 

tucked neatly under the occiput. The drop is now in- 
creased in frequency and held just below the point of 
spasm of the respiration. The third towel folded length- 
wise is now stretched over the lower third of mask, one end 
is tucked under the head, the other is left free (Fig. 69) . 

We now have two-thirds of the mask covered by towel- 
ing, the middle third is exposed and receives the ether 
dropped upon the mask. With this semi-open method 
almost every case can be subdued. When a particularly 
obstreperous case refuses to become relaxed the mask is 
covered with ether and the free end of the third towel is 
thrown over the exposed portion of the mask. In this 
manner outside air is practically excluded and the most 
refractory patient will become anaesthetized ( Fig. 70 ) . 

This towel method will be found very convenient and 
effective, as the mask is thereby held in place, leaving both 
hands of the anaesthetist free. 

A somewhat more simple procedure, but one requiring 
an additional accessory, consists of covering the open drop 
mask with a sheet of rubber dam, having a hole in the cen- 
tre through which ether is dropped. This method effec- 
tively restricts the admission of air, but is somewhat more 
cumbersome in manipulation (Fig. 71) . 

The advantages of the semi-open method over the open 
method in the late stages of induction and in maintenance 
are: 

1. Vigorous subjects may be anaesthetized. 

2. Less waste of ether. 

3. Less ether in the air of the operating room. 

4. Less likelihood of acapnia. 

5. Less loss of body heat. 



130 ANAESTHESIA 

6. Induction is more expeditious. 

7. Because of rebreathing, this method may be used 
with more safety where preliminary morphine and atropine 
have been given. 

The disadvantages, as compared with the open method, 
are as follows : 

1. Oxygenation not so good. 

2. Control not so delicate. 

3. Not entirely fool proof. 

4. Not so good for early induction. 

5. Not suitable for little children who are to be carried 
in maintenance for some time. 

The Closed Drop Method 

For all patients with the exception of very young chil- 
dren, seven years or under, the closed drop method is by 
far the best (all round) method of oral inhalation. When 
this method is employed with nitrous oxide followed by 
ether, it is not only most efficient from the anaesthetist's 
point of view, but it is also by far the pleasantest mode of 
anaesthesia for the patient. 

This method is separate and distinct from both the 
open and semi-open method. A suitable apparatus must 
be employed, if one wishes to secure the best results. The 
apparatus which may be had for the closed method of 
etherization is varied. Our task is to suggest features of 
value which should govern our selection. 

1. It must be possible, at the will of the operator, to 
absolutely exclude atmospheric air ; otherwise nitrous oxide 
cannot be satisfactorily used for induction. 



ETHER ANAESTHESIA 131 

2. It should be light in weight and rest comfortably on 
the face. 

3. It must be possible to clean and sterilize the appara- 
tus. Small inaccessible parts, and therefore difficult to 
clean, are to be discouraged. 

4. The rebreathing must be unobstructed. 

5. There should be some device whereby ether may be 
automatically given in small, frequent doses, in such a 
manner as to simulate the drop method. 

6. It should be possible to easily and frequently change 
the gauze or crinoline, placed in the apparatus for the pur- 
pose of assisting in the evaporation of the ether. 

7. It is a great convenience to have some arrangement, 
whereby atmospheric air may be freely given the patient 
without removing the inhaler from the face. 

8. It will be found that a transparent face piece, such 
as is offered by celluloid, will be exceedingly valuable in 
watching the vomiting, position of the throat tube and the 
color of the lips. 

When one wishes to employ N 2 and O for induction 
and the latter part of maintenance and recovery, the inlet 
for these gases should be situated at some point in the ap- 
paratus between the bag and the face piece, not, as is the 
usual custom, by means of a stopcock at the base of the 
bag. By the admission of N 2 and O in this way, we may 
have immediate results; we need not wait for the bag to 
be emptied. There should also be provided a valve, which 
will allow the escape of expirations, but which will prevent 
the admission of air during inspiration. 

The author has succeeded in embodying most of the 



132 



ANAESTHESIA 



foregoing principles in a device, shown in Fig. 72. Any 
contrivance which exhibits the same principles will give 
equally good results. The above-mentioned apparatus is 
a modification of a standard face piece, the detailed con- 
struction of which is unimportant since other face pieces 
might be substituted with equally good results. 

The following features of this apparatus are worthy 
of notice: 

1. A device for giving ether by the closed drop method. 




Fig. 72. — The author's apparatus for the administration of ether by the closed drop method 
and for gas oxygen ether anaesthesia. 

This consists of an ordinary oil cup with a sight feed. 
The cup is filled with ether as required, and the drop is 
regulated by a screw at the top. This cup forms a part of a 
section which may be easily slipped on and off the face 
piece section. 

2. A tube for the admission of the gases N 2 and O, 
located between the bag and the face piece. This is also 
part of the above-mentioned section. 

3. An expiratory valve for use when N 2 and O are 
used. 



ETHER ANAESTHESIA 133 

4. The entire apparatus weighs only two-thirds as 
much as the well-known Bennett. 

5. The face piece is comfortable and transparent. 

6. Atmospheric air may be readily and freely ad- 
mitted through the air valve without removing the face 
piece. 

7. The use of a roll of fine wire gauze, 100 to the inch, 
for an evaporating surface. 

The last feature named is of the utmost importance, 
as will be seen in the following consideration: The wire 
gauze in strips 2 inches by 15 inches is rolled up like a 
jelly roll. This roll is placed in the ether cup section so 
that the ether, which drops into the apparatus, will become 
entangled in its meshes. There is practically no obstruc- 
tion to the respiration, which passes freely through this 
wire tube. The evaporating surface is large, and the 
material does not collapse when wet with ether. 

Administration. — When the closed drop method is 
employed. 

Induction. — With the air vent open, the wire gauze in 
place, and the ether in the cup, the bag is filled with gas. 
The face piece is then adjusted and the patient is permitted 
to breathe the air. After a few moments, the air vent is closed 
and the patient breathes nitrous oxide to and fro. At the 
end of about forty seconds, or when the respirations become 
involuntary, as is shown by their increased depth and rap- 
idity, ether is very cautiously added drop by drop. The 
frequency of the drop is increased as rapidly as possible 
without causing spasm of the respiration. The rubber tube 
which admitted the N 2 may now be detached. The air 



134 ANAESTHESIA 

which may enter through this tube will not be found ob- 
jectionable. By opening the air vent during inspiration 
and closing it during expiration, we may oxygenate the 
patient and dilute the percentage of the ether in the bag. 
Stertor usually appears when we have vaporized about 
half an ounce of ether. 

Consciousness is lost easily and pleasantly. The period 
of excitement is reduced to a minimum. Spasm of the res- 
piration sometimes occurs, but muscular movements are 
rare. The respiration, unobstructed by tightly packed 
gauze, is usually full and deep ; the color responds quickly 
to oxygenation bj^ the atmospheric air. When it does not 
so respond, oxygen may rapidly be admitted through the 
tube designed for this purpose. The color of the lips may 
readily be seen through the transparent face piece. 

The lid reflex disappears and the masseters become re- 
laxed. The eyeballs soon become fixed and the pupils 
somewhat contracted. The light reflex, however, remains 
active and the corneal reflex sluggish. In this condition 
the patient enters the stage of maintenance. 

Before describing the stage of maintenance, we may 
say that the induction of anaesthesia by the closed drop 
method will give as good results, and occasionally better 
results, than the pour methods usually employed with other 
apparatus. It is in the stage of maintenance, however, 
that this method becomes most useful. 

Maintenance. — If the breathing is not perfectly satis- 
factory, we will do well to introduce a throat tube. (Fig. 
14.) This will guard against oral obstruction during the 
subsequent anesthetization. The operative procedure hav- 
ing been commenced without disturbing the patient, we may 
set the drop at a rate which seems most fit, in view of the 



ETHER ANAESTHESIA 135 

character of the induction. If the latter has been stormy 
and delayed, we will be obliged to exercise more control over 
the early stages of maintenance. At frequent intervals, 
depending upon the patient's color and the depth of the 
respiration, we fill the bag partially or completely with 
fresh air. If the inlet tube for the gas be open all the while, 
permitting the gradual escape of the contents of the bag, 
it will be found unnecessary to completely empty the bag, 
except when the respirations become unusually deep or 
the patient perspires freely. The simple adding of atmos- 
pheric air through the air valve will be all that is required 
to keep an even and tranquil anaesthesia. If the patient 
requires much ether, it is advisable to add air more fre- 
quently in addition to increasing the speed of the drop. 
This closed drop method approaches the ideal which is 
offered by the percentage method. With a free respiration, 
as is provided by the throat tube, a non-obstructing but 
efficient evaporating surface and a visible automatic drop, 
we have the patient under a delicate and even control. As 
one becomes familiar with the signs of anaesthesia, he can 
carry a low level, changing rapidly to a higher, as required 
by special manipulations. From a rather extensive and 
recent personal experience with this method, in experienced 
as well as in inexperienced hands, the author is satisfied that 
it is the best method where a variable but absolutely con- 
trollable level of maintenance is desired. 

Recovery. — We know of no method of anesthetization 
which will permit the anaesthetist to begin the stage of re- 
covery as soon as will the closed drop method. The anaes- 
thesia being under perfect control, one may, for example, 
in an abdominal section, stop the drop as soon as the peri- 
toneum is closed. While the patient rebreathes his own 



136 ANAESTHESIA 

expirations to and fro in the bag, he tends to lower the 
tension or percentage of ether present in his circulation. 
We may easily further decrease the strength of this ether 
by reducing the rebreathing and adding atmospheric air. 
Confidence born of control will allow one to attempt light- 
ness, which, under other circumstances, would court failure. 
If the anaesthetist is watchful, he can always recover the 
reflexes before the patient leaves the table. 

As the rebreathing induces respirations of large tidal 
volume, the ether in the circulation is rapidly thrown off 
and the second period of recovery or the return of con- 
sciousness is soon completed. 

The medical profession and the general public owe a 
debt of gratitude to Dr. Thomas Bennett of New York 
City for introducing gas ether anaesthesia in this country. 
We believe that the success of his apparatus lay in the 
fact that it was one of the earliest in which the gas ether 
sequence was used, and furthermore that the method em- 
ployed was a closed one. The device became known by 
its constant use by Dr. Bennett and later gave its author 
wide publicity. As this device is found in a large number 
of hospitals, it deserves more than a passing glance. While 
cumbersome and costly, it will yet give splendid results in 
experienced hands. (Figs. 73, 74.) It is arranged for a 
nitrous oxide ether sequence. The ether is given by pour- 
ing it upon the gauze, packed in the ether chamber through 
small holes in the sides of the same. Before starting, the 
ether chamber should be closely packed with gauze (it must 
be remembered that the patient does not breathe through 
this gauze, but around it) in the space between the cage 
and the air-tight wall of the ether chamber. The gauze in 
the ether chamber is then well moistened with ether, about 



ETHER ANESTHESIA 



137 



half an ounce being poured in. The indicator is turned to 
" air." The gas bag is filled and the face piece is applied. 
The patient is made to rebreathe N 2 0. When the respira- 
tions become deep and more rapid than normal, the ether 
is cautiously turned on. If there is no respiratory spasm, 
it is gradually increased. When full ether is reached, the 
gas bag is replaced by the rebreathing bag. A small 
amount of ether is poured into the ether chamber, through 
each of the three holes. Relaxation comes on quickly and 




Fig. 73. — Bennett apparatus, with gas attachment 
and bag for induction. 



Fig. 74. — Bennett apparatus with ether 
rebreathing bag for maintenance. 



the stage of maintenance is soon reached. When properly 
managed, the stage of induction is all that can be desired. 

During the stage of maintenance, however, we are 
likely to feel that improper provision has been made for: 

(a) The changing of the gauze, which has become 
water soaked by the condensed respiratory moisture; (b) 
the giving of small, constant doses of ether; (c) unob- 
structed rebreathing. 

Furthermore, we cannot see the patient's mouth 



138 ANESTHESIA 

through the opaque, metal mask and, after an hour or 
more, the weight of the apparatus becomes troublesome. 

Unless one is very expert, the patient will not be under 
proper control. The wet gauze will not hold the ether 
poured upon it, allowing the latter to run down into the 
face piece. With care and good judgment these disad- 
vantages are not so marked. They will be found especially 
noticeable, however, with the beginner, who has not de- 
veloped the skill necessary for their proper avoidance. 

The stage of recovery cannot be started as early as one 
would wish for the reason that the control is not sufficiently 
delicate. The return of consciousness is delayed, since it 
has been necessary to carry a high level of maintenance; 
a low level being dangerous, as spasm supervenes where 
ether is added too freely. 

We have taken the liberty of selecting the Bennett 
apparatus as a popular and widely used exemplification of 
a type, which does not offer the most satisfactory means 
of inducing and maintaining anaesthesia, especially from 
the point of view of the beginner. Long usage, mixed with 
interest and intelligence, as has been before mentioned, 
often overcomes these shortcomings. 

The device which the author employs is also one show- 
ing forth a type, the detailed construction of which is in- 
cidental and which may easily be improved upon. 

The Disadvantages of the Closed Drop Method as 
Compared With the Open and Semi-Open Drop 
Method 

1. The apparatus is more cumbersome and expensive. 

2. It cannot be used when the tidal volume is unusu- 
ally small, as in babies and very young children. 

3. It is not fool-proof. 



ETHER ANAESTHESIA 139 

The Advantages of the Closed Drop Method as Com- 
pared with the Open and Semi-Open Drop Method 

1. It may be used with more efficiency in a larger range 
of cases. 

2. The ability to use N 2 gives a speedier and pleas- 
anter induction. 

3. It is most economical in the use of ether. 

4. The body heat is preserved. 

5. The rebreathing prevents acapnia. 

6. Preliminary morphine medication may be used with 
greater safety. 

7. The control of the patient is more delicate and 
effective. 

8. The stage of recovery may be begun earlier. 

9. During the stage of induction and maintenance, 
oxygen may be given in the most effective manner, namely, 
mixed with C0 2 . 

10. During the stage of recovery N 2 and O may 
be used and much of the ether may thus be thrown off. 

11. The operating room is almost free from the odor of 
ether. 

12. The anaesthetist may give ether all day and at the 
close have absorbed little or no ether himself. 

Observations on the Use of the Open and Semi-Open 

Drop Methods in Large Clinics, with Special 

Reference to the Means Employed to Overcome 

the Objectionable Features of These Methods 

In observing the anaesthesia at various clinics, we are 

forced to the conclusion that differences of opinion exist 

in regard to the definition of " A good anaesthesia. " We 

are under the impression that a good anaesthesia implies: 

A rapid and pleasant loss of consciousness, a short period 



140 ANAESTHESIA 

of excitement, a relaxation, which comes on quickly and 
which is well under way before the operation is commenced, 
a stage of maintenance under the complete and ready con- 
trol of the anaesthetist and a knowledge, on the part of the 
anaesthetist, of the exact depth of the anaesthesia at any 
given time. To our surprise, we often find a satisfactory 
anaesthesia summarized in : A delayed and distressing loss of 
consciousness ; a period of excitement often prolonged and 
followed by rigidity extending well into the course of the 
operation, which is habitually begun so early that there is 
almost invariably a reflex rigidity as a consequence; an 
uneven stage of maintenance, not under good control and 
leading rather than being led by the anaesthetist. The 
keynote of a good anaesthesia appearing to be, to give as 
little ether as possible regardless of the convenience of 
the surgeon, who must adapt himself to this essential. 

There is no doubt that such a method of anaesthesia is 
seldom exposed to the danger of overdosage, or of vagus 
inhibition, because fortunately the anaesthetic is not chloro- 
form but ether. Ether may be given in this fashion with 
comparative safety by a lay person, who need pay little 
attention to the signs of anaesthesia, the essential indication 
being to increase the amount of ether administered when 
the patient coughs or moves, and to reduce the amount or 
stop the ether if the patient is quiet. 

The delay in the induction of anaesthesia by this method 
of open and semi-open drop ether is overshadowed by one 
or all of five reasons: 

1. The fact that operations are going on in more than 
one operating room at the same time, and visitors are not 
obliged to wait for the next patient but may be otherwise 
entertained. 



ETHER ANAESTHESIA 141 

2. The patient is anaesthetized on the operating table 
in the operating room, and the delay incidental to trans- 
portation after anaesthesia is induced is obviated. 

3. If the operative position is a difficult one to obtain, 
i.e. , for kidney work, the patient is placed in this position 
before the anaesthesia is induced. 

4. The preparation of the field of operation takes place 
as soon as the patient is on the table, usually before con- 
sciousness is lost. 

5. Lastly, and of great practical importance, the pa- 
tient is thoroughly restrained by strapping. This obviates 
the danger of his lifting his hand in a subconscious effort 
to protect himself when the first incision is made, as would 
certainly occur in many of these cases where the operation 
is begun during the early periods of induction. 

This control makes possible a method which otherwise 
could not be tolerated. 

The rigidity incidental to incomplete anaesthesia is 
largely overcome by the employment of large incisions and 
the use of self -retaining retractors. 

In discussing this method of anaesthesia, we try to sepa- 
rate it from the fame which it sometimes borrows from 
its environment and to consider it per se, as it would actu- 
ally appear if shorn of its surgical support and trans- 
planted to a locality where it would be obliged to stand 
upon its own merits ; for this is the condition obtaining with 
those who adopt this method. Possibly under some con- 
ditions no better method can be found. 

The Administration. — Patients who are able to walk 
are sometimes assembled in a small waiting room a short 
distance from the operating rooms. When the operating 
room is dressed, they walk in, disrobe and lie upon the 



142 ANESTHESIA 

table. A strap is then thrown over the knees and bands 
of webbing, sometimes two, sometimes four, hold the arms 
to side. 

The nurse speaks a few words to the patient and, after 
covering the eyes with gauze, begins the administration of 
ether by the drop method. The mask, at first some dis- 
tance from the face, is gradually lowered as anaesthesia 
progresses. Consciousness persists for from three to four 
minutes. Since the respirations are shallow, the induction 
is delayed so that at the end of ten minutes marked rigidity 
is often still present and reflexes to pain persist. The open 
drop mask is sometimes converted into a semi-open mask 
by winding a strip of gauze about it, something after the 
fashion of a bandanna handkerchief. The preparation of 
the field of operation begins before consciousness is lost and 
is usually concluded before the induction is well under way. 
When the preparation is complete, the incision is fre- 
quently made, often with little respect for the signs of 
anaesthesia. If the patient resists, the operator is con- 
strained to wait. If the resistance is slight it is usually 
overlooked. Since the patient is well restrained the danger 
of his hand finding its way to the wound is slight. The 
pain of the first incision usually stimulates the respiration 
so that a certain amount of ether is eventually absorbed. 

During the stage of maintenance, the chief symptoms 
observed are presence or absence of straining or movement, 
coughing or retching. Little effort is made to anticipate 
these signs and their occasional appearance is usually 
overlooked. 

The incomplete relaxation which obtains, prevents ob- 
struction of the airway by the falling back of the tongue, 



ETHER ANAESTHESIA 143 

but on the other hand permits masseteric spasm by reflex 
irritation. 

The stage of recovery is what might be expected from 
the use of this method, the advantages and disadvantages 
of which have been taken up in a preceding section, page 
127. 

It may not be unfair to assume then that the open or 
semi-open drop method is the routine method of choice in 
some clinics: 

1. Because it is so safe as to permit its administration 
by lay people. 

2. Because it is the belief of the authorities that the 
use of small amounts of ether is more important than the 
obtaining of complete relaxation. 

3. Because such a method involves apparatus of the 
simplest possible type. 

4. Because provision may be made for the delayed in- 
duction incidental to drop ether by placing the patient in 
the operative position on the operating table, in which posi- 
tion he is restrained and the anaesthetic started. The field 
of operation being prepared at once and little heed being 
paid by the audience, who are entertained in neighboring 
rooms. 

5. Because provision may be made for imperfect 
relaxation by employing large incisions and self -retaining 
retractors. 

The Vapor Method of Oral Inhalation 

In the vapor method of oral inhalation we offer ether 
to the patient in vapor form. The respiration has nothing 
to do with the production of this vapor, which is brought 
about by mechanical means. 

It is not our object to catalogue the various apparatus 



144 ANAESTHESIA 

at our disposal but to reduce the method to its simplest 
terms. We will attempt to describe the most simple form 
of vapor anaesthesia, a method which has given continued 
satisfaction in the hands of many operators. 
Apparatus. — 

1. Cautery bellows or tank of oxygen. 

2. A suitable bottle for vaporizing the ether. 

3. A suitable mask, through which the patient receives 
the vapor delivered. 

1. The bellows and the oxygen tank need no explana- 
tion. 

2. The wash bottle attached to the operating room oxy- 
gen tank will make a perfectly satisf actory vaporizing bot- 
tle. This is usually an eight-ounce bottle with a large neck, 
into which fits a rubber cork perforated with two holes. 
Through one of these holes passes a tube long enough to 
pass below the surface of the ether. Through the other a 
small tube, which reaches just below the cork. The cau- 
tery bellows or tubing from the oxygen tank is attached 
to the long tube, so that when air or oxygen is introduced, 
it will bubble through the ether. The short tube, for the 
exit of the vapor, is connected with tubing which leads to 
the face piece (Fig. 75). 

3. The ordinary semi-open drop mask may be em- 
ployed by passing the tube, which delivers the vapor, be- 
neath this. When purchasing a drop mask, however, the 
best plan is to buy one designed for use with vapor, as 
shown in Fig. 65. This mask will therefore serve the 
double purpose of drop and vapor mask. 

The vapor method of oral inhalation is especially 
adapted to babies and very young children. We know of 
no method which is subject to as delicate a control. The 




Fig. 75.— Apparatus for the vapor method of oral inhalation showing oxygen tank, cautery 
bellows, wash bottle in which ether is placed, Lumbard vapor mask. 



ETHER ANESTHESIA 145 

tidal volume of a baby's respiration is often so small that 
it will not properly vaporize ether dropped upon the mask. 
Xo argument is necessary to emphasize the value of the 
vapor method in these cases. A device for heating the 
ether container is unnecessary, as the evaporation is com- 
paratively slow. In those unusual cases where heat is 
desired, the most simple method of applying this is to set 
the ether bottle in a dish of hot water; any dish will do. 
We are never without hot water where an operation is to 
be performed, while electrical conveniences are frequently 
absent. The addition of heat increases the concentration 
of the ether vapor from 60 per cent, or less to almost 100 
per cent. See page TO. 

It will be found that the use of oxygen, instead of 
atmospheric air by the bellows, is not only more efficient 
because it provides thorough oxygenation, but, being auto- 
matic, it is much easier of administration and can readily 
be controlled. The expense is of small consequence, as the 
ether necessary to control an adult in this manner will be 
vaporized by less than twenty gallons of O per hour, repre- 
senting an expense of less than one dollar. An infant re- 
quires much less. 

The Administration. — The administration is exceed- 
ingly simple, our chief care being to give the vapor gradu- 
ally and to watch carefully for signs of deep anaesthesia, 
as exhibited by a rapid respiration and a fixed, dilated 
pupil. In very young children, our chief care should be 
to keep the small patient quiet with as little anaesthesia as 
possible. 

For any type of operation in babies and small children, 
where the oral method of inhalation will suffice, we believe 
that this vapor method will give the best results. 

10 



146 ANAESTHESIA 

Intrapharyngeal Inhalation 

In intrapharyngeal inhalation we do away as it were 
with the oral and nasal cavities and connect the pharyn- 
geal cavity directly with the source of the anaesthetic vapor. 
We in no way supplant either inspiration or expiration. 
The respirations remain as natural as where the ordinary 
oral methods are used. The method may be substituted for 
the oral method as soon as the pharyngeal reflexes are 
sufficiently under control to permit of the presence of the 
pharyngeal or nasal tube. 

The method is applicable in the case of any adult or 
child of ten years or over. The limit is marked by the 
tidal volume which the patient breathes, rather than the 
patient's age. 

We may speak of the method of intrapharyngeal in- 
halation as the method of choice in military surgery of 
the head and neck. 

Intrapharyngeal inhalation may be conducted (a) by 
a nasal tube, with or without rebreathing; (b) by a pha- 
ryngeal tube, with or without rebreathing. 

When the nasal method is used the largest tube ac- 
ceptable to the patient is employed. Tubes used for peri- 
neal draining, size 35 to 41 F., are entirely practical. 
These tubes are open at the end and have side openings as 
well. A single tube is all that is necessary. 

When induction is complete the tube is well lubricated 
and slipped gently into the nostril until it reaches such 
a point that the respirations pass freely through it. This 
point will usually be found at a distance of from 5 to 7 
inches from the tip. The distal end of the catheter may 
then be j oined to another piece of tubing of suitable length 
whose free end leads to the source of the ether vapor. In 
this method more or less respiration takes place through 



ETHER ANESTHESIA 



147 



the mouth. Excessive ventilation occurring in this way 
is controlled by placing wet towels over the patient's face 
or by packing the pharynx with gauze, thus inducing more 
or less rebreathing. When morphine and atropine are used 
as a preliminary this method is very satisfactory. If pre- 
liminarv medication has not been administered the mucus, 
which is prone to collect in the tube quickly, defeats our 
object by causing most of the respirations to take place 
around the catheter instead of through it. 





Fig. 76. — Showing pharyngeal tube and nasal tube employed for intrapharyngeal inhalation. 
The stylet is for intratracheal use. 



When the pharyngeal tube is employed, a specially 
designed tube (Fig. 76) or the tube shown in Fig. 14 is 
put into operation. This consists of the ordinary pharyn- 
geal tube supplemented by a short tubing at right angles 
to the distal end. Into one end of this tubing is placed 
a cork, over the other the large rubber tubing through 
which the patient breathes. 

When induction is complete the pharyngeal tube is in- 
troduced over the surface of the tongue. The tubing is 



148 



ANAESTHESIA 



connected and the distal end is attached to the source of 
the ether vapor (Fig. 77). 

When the pharyngeal tube is used practically the en- 
tire tidal volume of the patient is under control. This 
control will become complete if the lips are sealed with 
adhesive plaster and the nostrils are stopped with cotton. 

The method is ideal for head and 
neck work and is the one of choice 
where the operation is not in the oral 
cavity. 

When rebreathing is not desired 
the following simple method for the 
source of ether vapor may be used 
for both pharyngeal and nasal routes. 
An ether can is opened and emptied. 
Holes are then punched in the top of 
the can with bandage scissors so that 
a condition resembling Fig. 77 ob- 
tains. Half an ounce of ether is then 
poured into the can and the tube 
through which the patient breathes 
and which is connected at its proxi- 
mal end either to the nasal tube or to 
the pharyngeal tube is slipped over 
the top of the ether can. The patient now breathes in 
and out through the holes punched in the ether can. 
To increase the concentration of the ether vapor breathed 
the can is shaken, gauze is placed over the holes, and the 
flat of the hand grasps it firmly, thus imparting heat which 
hastens vaporization. 

When rebreathing is desired the following adaptation 
of the author's closed drop gas ether apparatus will be 




v 



Fig. 77. — The authors "tin can 
method. 



ETHER ANESTHESIA 149 

found satisfactory. With this method the oral will be 
found more satisfactory than the nasal route, because of 
the greater tidal volume permitted. When good muscular 
relaxation is secured, the face piece, consisting of rubber 
cushion and celluloid mask is removed by unscrewing a 
single nut. The distal end of the pharyngeal tube is then 
slipped over all and a condition as shown in Fig. 79 obtains. 

In practice this method yields complete control for 
rebreathing, and pure oxygen gas may be used at will. 

The disadvantages of intrapharyngeal inhalation are 
as follows : 

It is not suitable for small children. 

It requires close attention, for it does not give a con- 
stant but a variable maintenance. 

Its use implies familiarity with general anaesthesia. 

It requires preliminary morphine and atropine. 

The advantages of intrapharyngeal inhalation are as 
follows : 

It is ideal for military surgery. 

Available for all head and neck work in adults. 

Any volatile anaesthetic agent may thus be offered to 
the patient. 

It is simple, portable, and economical. 

It offers all the advantages of rebreathing. 

Where rebreathing is desired the apparatus used for 
the stage of induction can be conveniently used with the 
simple addition of a throat tube and connecting rubber 
tubing. 

Intratracheal Inhalation 

In intratracheal inhalation we practically do away 
with the oral nasal cavities, the pharynx and the glottis and 
offer the vapor to be respired directly into the trachea of 
the patient. We do not supplant in any way either in- 



150 ANAESTHESIA 

halation or expiration. Our object in this method is to 
insure freedom of the respiration in the face of respiratory 
obstruction secondary to the operative procedure, i.e., as 
in the case of excision of the tongue or larynx. 

In intratracheal inhalation the inspiration and expira- 
tion both pass through the tube, while in intratracheal insuf- 
flation only the inspired air passes through it, the expired 
air passing around it. For this reason then the tube for 
intratracheal inhalation should be as large a diameter as 
possible, virtually packing the larynx by its presence. It 
has been found that the adult male larynx will accommo- 
date a No. 41 P. perineal drainage tube without discom- 
fort. The author has repeatedly used a tube of this size in 
full-grown men. The female larynx is somewhat smaller, 
but will accept a No. 35 F. without difficulty. 

If we realize that the vocal cords are not mere mem- 
branes stretched across the glottis, but, on the contrary, 
massive tissues offering a comparatively large surface for 
contact with an intratracheal tube (Fig. 76) we will not 
be surprised to learn of the absence of untoward effects 
following intubation. Laryngeal pain, hoarseness, or 
aphonia have not occurred in the cases under our observa- 
tion. One or two patients complained of tenacious mucus 
which they found difficult to expectorate. 

Inasmuch as the respirations must be carried on unas- 
sisted through the catheter in use, it is absolutely necessary 
that this tube be free from mucus. For this reason prelim- 
inary morphine and atropine must be used. * 

The technic of intubation will be found fully described 
on page 164 under Insufflation Methods. 

When the inhalation methods are used, however, a soft 
rubber tube (Fig. 76) (perineal drainage tube) is used 



ETHER ANAESTHESIA 151 

in place of a small silk woven catheter. As this cannot be 
rendered rigid by immersion in ice water a stylet must be 
used. This consists of a simple piece of straight wire 
(Fig. 76) bent so short that it cannot project beyond the 
rubber tube and thus traumatize the tissues. 

The larynx is exposed with the Jackson laryngoscope 
and the tube previously moistened with water or a thin 
film of lubricant is introduced with wire in place. When 
the intubation is complete the wire is removed and the dis- 
tal end of the tube is attached by a second tube, either to 
the inhaler, as is shown in Fig. 78, when rebreathing is de- 
sirable, or to the ether can as is shown in Fig. 77, when re- 
breathing may be dispensed with. 

If positive pressure is desired for distention of a lung as 
in the case of an operation for decortication, the laryngeal 
tube must be attached to the rebreathing bag, as shown in 
Fig. 78. By blowing air or oxygen under pressure into this 
bag positive pressure in the lungs may be secured. 

Intratracheal inhalation is a method of expediency. 
It is not the method of choice when insufflation anaesthesia 
is available. It should be employed only by the experi- 
enced anaesthetist. It requires closer attention than does 
intratracheal insufflation, for there is no automatic assist- 
ance offered during inspiration. Indeed, the procedure 
places an artificial obstruction to normal respiration by the 
presence of the tube in the larynx. On the other hand, it 
is a method which should be familiar to every anaesthetist, 
for it is comparatively safe, simple, and efficient. When 
indicated, as in operations about the larynx or oesophagus, 
it is extremely valuable. It is the natural method to em- 
ploy in the war surgery of the Casualty Clearing Stations, 
Evacuation Hospitals and ambulances at the front. 



152 ANAESTHESIA 

ANESTHESIA BY INSUFFLATION METHODS 
Oral Insufflation 

Oral insufflation consists of blowing the anaesthetic va- 
por into the patient's mouth. 

We may use either a small volume of highly concen- 
trated vapor, for example that which results when air or 
oxygen is bubbled through ether (see page 144, Fig. 75) 
or we may use a large volume of low concentration, as is 
the case when intrapharyngeal insufflation is administered 
by the Connell aneesthetometer (see page 161). 

The apparatus for this method is identical with that 
shown in Fig. 75, with the exception that an oral tube 
or mouth gag (Fig. 81) is substituted for the vapor mask. 

An apparatus similar to that shown in Fig. 81 is very 
useful and convenient when it is desirable to administer 
straight chloroform or the C. E. mixture intra-orally. The 
container in this case is a so-called potato tube used for 
bacteriological work. One of the tubes perforating the 
rubber cork, the one through which the air is delivered, 
should extend into the liquid; the other should terminate 
near the bottom of the cork. The oral tube shown in Fig. 
81 is convenient. The mouth gag is equipped with spe- 
cial tubing which opens at the jaws of the instrument. One 
should always be careful to see that clotted blood is not 
boiled in these tubes and thus obstruct the flow of the vapor. 

Oral insufflation is usually the method employed when 
chloroform is the anaesthetic and a nasal or intra-oral oper- 
ation is being done. It is occasionally useful in small chil- 
dren for operations in the same region, ether in this case 
being the anaesthetic. 



ETHER ANAESTHESIA 153 

Intrapharyngeal Insufflation 
In intrapharyngeal insufflation, instead of blowing 
ether into the patient's mouth, we go a step further and 
blow it into the posterior pharynx. It is unnecessary to 
state that the ether must be previously vaporized. 

There are also two distinct methods of giving ether by 
the intrapharyngeal insufflation : 

(a) In the first, we supply to the patient a mixture of 
ether and air of sufficient volume to meet all his respiratory 
needs. This volume ranges from twelve to eighteen liters 
a minute. We not only do not depend upon the addition 
of atmospheric air, but we exclude it by giving the vapor 
under a pressure ranging from 20 to 40 mm. of mercury. 

(b) In the second, we give the patient a small 
volume of very concentrated ether and depend upon the 
mixture of atmospheric air to both dilute this and supply 
the total volume necessary. 

The first method is of course the ideal, since it enables 
us to completely control the percentage of the ether in- 
haled. Knowing the limits of depth and lightness in terms 
of vapor tension to be about 180 mm. to 50 mm. (see page 
64 et seq. ) our control of the patient well-nigh approaches 
perfection. 

This type of intrapharyngeal insufflation is best exem- 
plified by the apparatus known as the anassthetometer, 
designed by Dr. K. Connell (Fig. 82) . 

Apparatus for Intrapharyngeal Insufflation. — 
There are three divisions: 

1. The air supply. 

2. The mixing chamber. 

3. The section for delivery to the patient. 

1. The air supply may be procured by foot power, 



154 ANESTHESIA 

steam or electricity. There may or may not be a reservoir 
for the air before entrance to the mixing chamber. 

Foot power will be found satisfactory where the bel- 
lows shown is employed. Steam power is the type used 
at Roosevelt Hospital, New York City. The plant is 
somewhat costly and cumbersome for any but a large in- 
stitution. Electrical power (Fig. 87) is quite satisfactory. 
(See Int. Hosp. Record, Nov., 1912.) 

2. The mixing chamber. The Ansesthetometer. 

3. The section to the patient consists of a rubber tubing 
to which is attached a so-called nasal tube. (Figs. 83 and 
84.) 

The nasal tube is constructed of nickel-plated brass of 
a shape corresponding to the patient's face. It ends in two 
nipple-like projections which are bent so as to enter the 
nostrils and prevent angulation of the catheters which are 
attached thereto. The catheters usually employed are No. 
18 French, velvet-eyed. Special catheters have been de- 
signed having open ends resembling a small rectal tube in 
construction. These, while efficient, are not entirely neces- 
sary. The length of the catheter to be used is equal to the 
distance between the alee of the nose and the auditory 
meatus. This distance carries the tube well into the pos- 
terior pharynx. If the tube is made too long it will enter 
the oesophagus and dilate the stomach. It must be prop- 
erly lubricated or a nose bleed will result. 

The Administration. — The induction is usually 
brought about by the employment of a semi-open or closed 
drop method. When the patient has entered the stage of 
maintenance, the vapor apparatus is started, the indicator 
being placed at 60 or 70 mm. The catheters, well mois- 
tened with the patient's saliva, are slipped gently into each 
of the nostrils. If one is occluded, both catheters may be 




%Q 




Fig. 78. — Intrapharyngeal inhalation with Fig. 79. — Intrapharyngeal inhalation with 
rebreathing, nasal method. rebreathing, oral method. 




Fig. 80. — Jackson laryngoscope with Tieman pocket flashlight adapter. 




Fig. 83.— Nasal tubes. 



Fig. 84. — Nasal tube in place. 




Fig. 82— Anaesthetometer (Connell). 




Fig. 83.— Nasal tubes 



Fig. 84. — Nasal tube in place. 



ETHER ANAESTHESIA 



155 



placed in one nostril. In accomplishing this, one should ele- 
vate the tip of the nose and keep the catheters close to the 
floor of the nares. The operation is completed by placing 




Fig. 85. — Intrapharyngeal anaesthesia, showing the insertion of the nasal tubes. The 
catheters are moistened with the patient's saliva. The nose is tilted backward and the tubes 
are passed along the floor of the nose downward and backward. 




Fig. 86. — Intrapharyngeal anaesthesia. Nasal tubes in place and strapped to the patient's 
forehead by adhesive plaster. 

an adhesive strip over the nasal tube. Fig. 85 shows inser- 
tion of the catheters. 

Fig 86 shows catheters in position. 

The anaesthesia may now be continued with the head 



156 ANAESTHESIA 

covered by towels and the anaesthetist at some distance 
from the patient. One gradually reduces the percentages 
beginning at the end of half an hour, until 40 or 50 mm. is 
reached, at which point the patient may be carried for 
hours. 

As has been before stated this type of anaesthesia is con- 
stant and does not attempt to vary its level according to 
the manipulations of the surgeon. 

The anaesthetist must be continually alive to the patient 
and the apparatus, however, for trouble may arise in either 
or both. This trouble will be more difficult to detect and 
must be met more promptly than where a more simple 
method is employed. 

The second method, in which a small volume of very 
concentrated ether is given, depending upon the patient to 
dilute this with atmospheric air, is offered for that very 
large class of patients, particularly in private work, where 
the percentage method is not available. This method at its 
best but approaches the ideal offered by the former. It will 
be found very serviceable and efficient, however, if prop- 
erly managed and will enable one to meet those many re- 
quirements for nasal anaesthesia encountered outside the 
hospital. 

The Apparatus. — The apparatus is identical with that 
suggested for the vapor method of oral insufflation with the 
difference that we substitute the nasal tubes for the vapor 
mask. A throat tube is also necessary. 

When intrapharyngeal insufflation is administered in 
this fashion, it is very important to use the throat tube. 
This will insure the proper tidal volume and sufficient air 
to dilute the concentrated ether delivered into the pharynx. 
In order to keep the patient sufficiently anaesthetized, how- 



ETHER ANESTHESIA 157 

ever, one will find it necessary to induce a certain amount of 
rebreathing. This is most easily accomplished by the 
towels which are placed over the patient's head for the 
asepsis of the field of operation. These towels may, with 
advantage, be placed in position at the early convenience 
of the operator. 

When in position they should not lie directly upon the 
rebreathing tube but at some distance from it. 

The Administration. — Anaesthesia is induced by the 
open, semi-open or closed drop method. When the stage 
of maintenance has been entered upon, the catheters are 
slipped gently into place. Ether vapor is then slowly bub- 
bled through these (preferably by oxygen) into the poste- 
rior pharynx. The throat tube should now be introduced. 
If the ether vapor causes cough or spasm, stop the vapor 
but do not remove the tubes. Give ether orally by the drop 
method. Tolerance will soon be established for the vapor, 
and when spasm no longer occurs the vapor will be freely 
admitted and the drop method discontinued. The mask, 
however, is held over the mouth until complete control of 
the patient is established. The freedom of both hands 
which the oxygen method affords at this stage will be found 
a great convenience. When the sterile towels are placed 
over all, the anaesthetist should make sure that they do not 
block the pharyngeal tube. In this type of maintenance 
we must watch the patient somewhat more closely than in 
the percentage method. For our maintenance is here of 
the variable type and depends upon the signs imme- 
diately expressed by the patient for an elevation or de- 
pression of the level which is carried. It is always safer 
to carry the patient too low than too high, for many 
of the signs are masked. As we depend chiefly 



158 ANAESTHESIA 

upon the muscular signs and the respiration, it is safer to 
allow the patient to " come out " now and then to the point 
of a slight spasm of the respiration than to keep him 
" deep " all the while. 

The Indications for Intrapharyngeal Insufflation 

1. Operations on the head and neck excluding intra- 
nasal operations ; glands of the neck, tonsils and adenoids ; 
tumors of the face; intraoral operations. In operations 
for hare lip and cleft palate, the vapor may be delivered by 
one catheter through the intact nostril. 

2. Whenever the immediate proximity of the anaesthe- 
tist endangers the asepsis of the field of operation, as in 
upper abdominal operations ; breast operations ; operations 
on the shoulder or chest. 

Contraindications 

When the percentage method of intrapharyngeal in- 
sufflation is employed, the method may be used in any type 
of case with the possible exception of the very young and 
those patients who have double nasal obstruction, or who 
are to suffer nasal manipulations. 

When the variable method by air bulb or oxygen is 
used, the method is contraindicated in all cases which do not 
specifically demand the method. This is because this varia- 
ble type depends much more on the signs exhibited by the 
patient for even progress of the anaesthesia than does the 
constant or percentage type. In these cases, since we are 
unable to constantly follow the eye signs and the color, we 
are working at a disadvantage which, when avoidable, 
should not be incurred. 



ETHER ANAESTHESIA 159 

Intratracheal Insufflation 
In intratracheal insufflation we deliver- ether vapor 
directly into the trachea of the patient, usually at a short 
distance from its bifurcation. We do not intend by this 
method to supplant the normal respiratory efforts by an 
artificial respiration, but to deliver the ether in a position 
most available for use by the patient. Instead of having two 
tubes delivering vapor into the pharynx, as is the case in 
the pharyngeal method, we have one long tube delivering 
vapor into the trachea, past the site of the vocal cords and 
upper air passages, where obstruction to the respiration is 
prone to occur. 

We provide neither the inspiratory nor the expiratory 
effort. By placing our vapor directly into the rigid res- 
piratory tree, beyond all obstruction, under a positive 
pressure of from 20 to 30 mm. of mercury, we naturally 
make inspiration easy for the patient. This is evident in 
the shallow respirations which he experiences. By using 
a tube of a much smaller diameter than the glottis, we pro- 
vide for the free escape of the expirations and any excess 
vapor admitted. We do not here, as in intrapharyngeal 
insufflation, use concentrated ether vapor, diluting this with 
the atmospheric air, but we give a volume sufficient for all 
the respiratory needs of the patient. This volume, under 
sufficient pressure, is such that even during the inspiration 
with the glottis, but partially obstructed by the tube, no at- 
mospheric air will enter ; there will be no inward flow at any 
time into the trachea along the sides of the tube. On the 
contrary, there should be a constant flow to the outside. 
This flow will naturally be less at the time of inspiration 
but.it will never altogether cease except when the delivery 
is cut off. 



160 ANESTHESIA 

If this idea of a constant flow out of the lungs is under- 
stood, then the great value of this method will be seen in 
cases suffering from hemorrhage or vomitus in the upper 
respiratory tract. We might imagine such an anaesthetized 
patient entirely immersed in water and yet receiving none 
in his respiratory tree. Sufficient pressure (20-30 mm. 
Hg) , is necessary, not only for the exclusion of atmospheric 
air but in order to prevent the lungs from collapsing when 
the intrathoracic pressure is withdrawn during operations 
in the thorax. 

The lungs are normally distended by virtue of the nega- 
tive pressure in the thoracic cavity. This appears to be due 
to the fact that these structures remain smaller than the 
thorax in the course of development. The negative 
pressure may also be represented by the natural elastic- 
ity of the lungs. If the pleural cavity is opened and 
this elasticity allowed to act, the lungs will collapse. 
The pressure varies from 4.5 mm. at expiration to 7.5 at 
inspiration. 

Obviously then, if we are delivering vapor into the 
trachea at a pressure of 20 mm. when the chest is opened, 
the lungs will have a tendency to expand rather than to 
collapse. This is what actually occurs: 

Since the lungs do contract at regular intervals during 
normal respiration, we should simulate this action by fre- 
quently releasing the positive pressure. We do this in 
practice. 

Since the interchange of the gases in the lungs results 
chiefly from diffusion rather than from actual replacement, 
a constantly changing stream of oxygenated vapor in the 
trachea and large bronchi will serve the vital purposes 
of respiration. We may then, with the greatest benefit, 



ETHER ANAESTHESIA 



161 



employ this method in artificial respiration ( see page 29 ) 
where free diffusion is present in the lung tissue, that 
is in those oases where fluid is absent, drowning cases, 
etc., excluded. In the normal case, however, it is unsafe 
to continue the administration in the face of suspended 
respiration. 




Fig. 87. — The Connel] Electrical Blower and Suction Apparatus for all types of insufflation 
anaesthesia. A simplified ansesthetometer which gives splendid service. 

Apparatus. — 

1. Connell's ansesthetometer. 

2. Intratracheal catheter. 

3. Laryngoscope and mouth prop. 

1. The ansesthetometer (Fig. 82 ) has already been men- 
li 



. 



162 



ANESTHESIA 



tioned on page 62 and in connection with intrapharyngeal 
insufflation on page 150 et seq. 

2. The intratracheal catheter (Fig. 88). The best 
tube is the ordinary silk-woven urethral catheter (size 24- 
French) with a side opening near its end. The diameter 
of the catheter should be less than one-half the diameter of 
the glottis. A mark should be made 26 cm. from the tip. 




Fig. 88, — Intratracheal Catheter and special mouth prop. 



This mark indicates the limit to which the catheter may 
be introduced. This mark should not be permitted to pass 
the incisor teeth. In the normal patient such a catheter 
introduced this distance will be about 5 cm. above the bifur- 
cation of the trachea. As a rule it will be found that the 
tube must be pushed once again the distance between the 
incisor teeth and the glottis. 



ETHER ANAESTHESIA 



163 



3. The Jackson laryngoscope has proven entirely effi- 
cient (Figs. 80 and 89). This instrument affords a direct 
electrically illuminated view of the glottis. By this inspec- 
tion we are enabled to estimate the size of the catheter nec- 
essary and to introduce it with full knowledge that it is in 
the trachea and not in the oesophagus. The laryngoscope, 




Fig. 89. — Jackson laryngoscope and rheostat . 

which contains a small dry battery in the handle, is the most 
convenient pattern. 

The mouth prop (Fig. 88) is for the purpose of 
protecting the catheter from accidental injury as it lies 
between the upper and lower incisor teeth. 



164 ANAESTHESIA 

The Administration. — Preliminary preparation: 

(a) Place half a dozen silk- wound urethral catheters, 
each marked 26 cm. (10-1/2 inches from the tip) in a pan 
of ice-water. 

(b) Start the anaesthetometer so that it is delivering 
50 mm. vapor tension. See that the emergency gauge 
which releases all pressure over 20 mm. Hg is in good 
working order. Regulate the pressure between 18 and 20 
mm. of Hg. 

(c) Have a foot bellows at hand for an emergency 
(Fig. 79). 

(d) See that the electric lamp in the laryngoscope is 
in good condition. 

In order to successfully administer an anaesthetic by the 
method of intratracheal insufflation it is essential that anaes- 
thesia be completely induced by the oral method. The 
semi-open or close drop method may be employed. If in- 
tubation be attempted before the larynx has become anaes- 
thetized, spasm will supervene, which will prevent satis- 
factory maintenance by this method. 

The technic of intubation is as follows: The patient, 
having been well anaesthetized (lid reflex gone, jaw re- 
laxed, eyeballs fixed, pupils contracted or slightly dilated, 
corneal reflex gone in both eyes, and the light reflex slug- 
gish in the presence of a good color and stertorous respira- 
tions), and lying on his back flat on the table, the head is 
grasped by the right hand and forcibly extended so that 
the chin is almost on a straight line with the sternum and 
neck ( Fig. 90 ) . The laryngoscope is grasped in the left 
hand, as shown in the illustration. It is then slipped over 
the now dependent upper aspect of the tongue until the 
epiglottis is brought into view. The lip of the instrument 
is then slipped over this and the base of the tongue thus 



ETHER ANESTHESIA 



165 



elevated. The glottis, well illuminated by the small elec- 
tric lamp at the distal end of the instrument, is now in full 
(Fig. 91). With the laryngoscope still grasped in 



view 



the hand, we select a catheter of the proper size with our 
right and slip this through the laryngoscope into the glottis, 
up to the 26 cm. mark. A hissing of air through this will 
now follow. The patient often coughs more or less vio- 
lently depending upon the completeness of his induction. 




Fig. 90. — Intratracheal Anaesthesia. The patient is in the dorsal position and the operator is 
forcibly extending the head preliminary to exposure of the larynx by the Jackson laryngo- 
scope which he holds in his left hand. Jackson technic. Roosevelt Hospital Report, 1915. 
(Courtesy of Dr. L. Booth.) 

This quickly passes off, however, and regular breathing is 
quietly resumed. As the catheter passes into the trachea, 
a hissing of air through it will be heard. This is a guaran- 
tee that the catheter is properly placed. When this sound 
is not heard, one should suspect that the tube has slipped 
into the oesophagus. The mouth prop is now placed in 
position, the catheter running through it and the delivery 



166 



ANAESTHESIA 



tube from the machine attached to this. The situation now 
resembles the intrapharyngeal, after the delivery through 
the nasal tubes has begun. Our duties are also the same 
with the exception that we must interrupt the flow two or 
four times a minute by pinching the tube. We also watch 
the pressure very carefully and observe with particular 




Fig. 91. — Intratracheal anaesthesia. The larynx is exposed to view by inserting the laryn- 
goscope under the tongue and epiglottis and forcibly lifting these structures. When the larynx 
is in plain view, the catheter is introduced as is shown in the photograph. Jackson technio, 
Roosevelt Hospital Report. (Courtesy of Dr. L. Booth.) 

care the respiratory movements of the patient. With this 
form of anaesthesia properly administered the maintenance 
is ideal. 

We anticipate obstruction to the respiration. We 
deliver a constant vapor of sufficient concentration in a 
volume equal to all the respiratory needs of the patient. 

The stage of recovery must be delayed, since the com- 
pletion of the first half of this stage, namely the complete 



ETHER ANAESTHESIA 167 

return of the reflexes, cannot be permitted while the tube 
is in the trachea. Following the withdrawal of the tube a 
certain degree of acapnia results from the excessive venti- 
lation which has been carried on, thus inducing a diminished 
C0 2 content in the blood. 

After-sickness is the exception. There is seldom, if 
ever, any evidence of irritation to the vocal cords due to 
friction by the catheters, even though the latter have been 
in contact with these structures for two hours or more. 

Trouble. — 1. The chief difficulty will be found to be 
the introduction of the tube. Three factors are necessary 
to obviate this trouble: 

1. Deep ansesthesia before intubation is attempted. 

2. Complete extension of the head. 

3. Direct vision of the glottis. 

2. A catheter too large in diameter thereby obstructing 
the return flow or introduced too far, i.e., into the bronchus, 
which it may partly or completely occlude, will subject the 
lung to destructive pressure. If there is doubt as to the 
proper position of the catheter this may be partially with- 
drawn, then introduced until it strikes an obstruction, i.e., 
the bifurcation of the trachea, when it is again withdrawn 
an inch. 

3. The tube may have entered the oesophagus ; in this 
case the respirations do not whistle through it. 

4. The pressure should not only be regulated by a blow- 
off but should be constantly readable on a Hg. manometer. 

5. The ansesthetometer may of course get out of order 
and the pump may stop, which difficulties must be antici- 
pated and properly met. 

The method is neither dangerous nor difficult when one 
understands the object to be achieved and when one is 
familiar with the apparatus which he is to use. 



168 ANESTHESIA 

The reader will doubtless conclude that, however ideal 
this method may be, it is debarred from the possibility of 
ever becoming a routine method for all types of cases, 
because of the technic and the complicated apparatus 
involved. 

Broadly speaking we may say that for hospital work, 
where the ansesthetometer has been installed, the question 
of apparatus may be ignored. One becomes familiar with 
this modified gas-meter and ceases to be surprised at its 
accuracy and constancy. Real trouble is quite exceptional 
and when it does occur one feels as when one's watch stops. 
The only thing to do is to have it fixed. We have nothing 
else which will give us results which are so unvarying. 

The crux of the whole question is the intubation and its 
advisability or inadvisability. The theory and the practice 
of this procedure will certainly form obstacles to the fre- 
quent and widespread use of this method. 

The Advantages of Insufflation by the Intra- 
tracheal Method 

1. Specifically indicated in intratracheal operations, in 
order to prevent the collapse of the lung. 

2. In intraoral operations, excision of the tongue, re- 
moval of the lower jaw, cleft palate, etc. 

3. In operations on the trachea and the larynx. 

4. For operations about the head and neck in general. 

5. When vomitus may collect in the upper air passages, 
as in emergency operations for intestinal obstruction. 

The Disadvantages 

1. A special knowledge of technic is necessary. 

2. Complicated and costly apparatus are needed. 

3. Deep anaesthesia must be induced before the tube 
may be introduced. 



ETHER ANESTHESIA 169 

THE ADMINISTRATION OF THE ANAESTHETIC 
PER RECTUM 

We have considered the most commonly used and the 
most practical forms of administering the anaesthetic by 
the indirect method, namely oral, pharyngeal and intra- 
tracheal insufflation. 

The chief reason for the effectiveness and safety of this 
route lies in the enormous capillary surface exposed to the 
action of the anaesthetic vapor. This surface has been es- 
timated as being equal to an area of 90 square meters or 
equal to the surface presented by a balloon twenty feet in 
diameter. 

It is possible, however, to induce and maintain anaes- 
thesia by the injection of a suitable solution into the 
rectum. 

This method while apparently simple is yet so fraught 
with danger that its use should be restricted to the expert 
anaesthetist. It should be employed only in the face of 
special and urgent indications, such as bronchoscopy or 
where it is impossible to secure a proper intratracheal 
apparatus. 

Ether may be given per rectum when olive oil or oxy- 
gen is used as a vehicle. 

Oxygen ether vapor per rectum has been used inter- 
mittently for the last ten or fifteen years. With this 
method it is not practical, however, to induce anaesthesia. 
Its chief value is for the maintenance of anaesthesia other- 
wise induced. Since we have other and better methods of 
maintaining anaesthesia, it will be of little value to enter 
more fully into a discussion of this rather obsolete method. 

Anaesthesia by the inj ection of olive oil and ether, how- 
ever, will require a somewhat more lengthy consideration. 



170 ANAESTHESIA 

This method, introduced during the last two years, while 
certainly attractive from several points of view, is perni- 
cious because of its apparent simplicity. To give an enema 
of a mixture of ether and olive oil, which will result in sat- 
isfactory surgical anaesthesia, appears so simple upon 
superficial consideration that thoughtless anaesthetists have 
naturally been attracted and without counting the cost 
have not only endangered but killed their patient. 

A technic of such apparent simplicity, as is described 
for the proper administration of this method, should have 
no intricacies into which the unwary may blunder. A 
method demanding experience and great care should be 
safeguarded by the immediate report of fatalities directly 
or remotely due to the method. 

The small surface which the gut offers for the absorp- 
tion of the ether vapor implies the need of a concentrated 
solution placed in situ and necessarily absorbed slowly. 
This solution when once introduced into the rectum passes 
more or less completely out of our control. 

The rate at which this vapor is thrown off by the lungs in 
the human being will differ from that in the small, hairy animals, 
whose respiratory mechanism is intended to dispose of a propor- 
tionally much larger amount of heat and moisture than does the 
human. 

Observations made upon cats and rabbits involving the 
element of respiration will not form a reliable basis upon 
which to judge human beings. 

As long as we are obliged to depend upon the reliability 
of colon irrigation to remove an overdose, and upon the 
dilution of the circulation b}^ an intravenous solution when 
the former has proven ineffective, we should approach this 



ETHER ANAESTHESIA 171 

method with the utmost caution. Until we may consider 
statistics from the unreported deaths due to this method, 
our policy in the absence of urgent indications and expert 
control should be one of " watchful waiting/' 

While we are aware of excellent results which have fol- 
lowed the use of this method, we feel that it is not adapted 
for routine use; certainly not for the tyro and the occa- 
sional anaesthetist. 

Apparatus.— 

1. Eight-ounce measuring glass. 

2. Olive ,oil and ether. 

3. Catheter and rubber tubing. 

4. Funnel. . 

We take the liberty of following here the directions 
given by Dr. Gwathmey, the originator of the oil method. 

Preliminary treatment: Castor oil the night before, 
followed in the morning by warm water enemas, one hour 
apart until the return is clear. The patient may then be 
allowed to rest for two or three hours. 

One hour before operation 5 to 20 grs. of chloretone in 
suppository form are given; for the chlorotone we may 
substitute 2 to 4 drachms of paraldehyde in an equal 
amount of olive oil. 

Twenty minutes before operation a hypodermic of 1/12 
to 1/4 grs. of morphine and 1/200 to 1/100 gr. of atropine 
may be given. 

The Solution. — Adults are given a mixture consisting 
of ether Oz. 6, olive oil Oz. 2 ( a 75 per cent, mixture) . The 
size of the dose is reckoned upon a basis of Oz. 1 of the 
mixture to every 20 lbs. of body weight ; i.e., man weighing 
140 lbs. would need Oz. 7. 

Children are given a mixture consisting of ether Oz. 3, 



172 ANESTHESIA 

olive oil Oz. 3 (a 50 per cent, mixture). The size of the 
dose is reckoned as with adults. 

The Administration. — With the patient in the 
Simms' position (see Fig. 21), in his own bed, the catheter 
(24 F.) is introduced about four inches into the rectum. 
The oil ether mixture is then allowed to flow in, allowing at 
least one minute for each ounce. 

The patient quickly becomes drowsy. Ether appears 
on the breath in from five to ten minutes. Excitement may 
be moderate or entirely absent. After a time, ten to thirty 
minutes according to the absorptive power of the colonic 
mucous membrane of the patient in question, he may be 
placed on the stretcher and conveyed to the operating room. 
The stage of maintenance is controlled by increasing 
or decreasing the freedom of the respiration, i.e., a towel 
over the face will cause the patient to sink into deeper nar- 
cosis by virtue of the rebreathing of the expired ether. On 
the other hand, a throat tube (see Fig. 14), will, by in- 
creasing the freedom of the respiration and consequently 
the amount of the ether thrown off, lower the level of the 
maintenance. 

Occasionally one is obliged to supplant the rectal ad- 
ministration by the drop method. If the respiration should 
show signs of shallowness or failure, the ether and oil 
injected should be immediately withdrawn by reintroduc- 
ing the catheter and allowing the retained solution to run 
off. In the event of failure of the respiration, rebreath- 
ing of C0 2 may be beneficial. If ineffective it is recom- 
mended that a vein be opened and from 1000 to 2000 cc. 
of normal saline injected with a hope of reducing the ether 
tension in the anaesthetized tissue. When the operation is 
well under way it has been found advisable to withdraw 



ETHER ANAESTHESIA 173 

as much of the injection as may be reached with the cathe- 
ter. At the completion of the operation a cold soapsuds 
enema is introduced high into the colon. This is then 
drawn off and two to four ounces of olive oil are introduced, 
with a view of neutralizing any ether which may remain 
unexcreted. 

The Advantages of the Method 

When efficient, the nature of the induction in the pa- 
tient's bed is certainly a great boon. 

The apparatus is most simple and economical (this for 
many is the " raison d' etre ") . 

The control when effective is most simple, i.e., increas- 
ing the freedom of the respiration by a tube to lighten the 
anaesthesia, decreasing it by a towel over the face to deepen 
it. 

When the intratracheal method is not available this 
method may be used with satisfaction for operations on 
the oral passages, the nasal passages and the neck. 

The Disadvantages of the Method 

1. It is certainly dangerous. 

2. The preliminary preparation is frequently inefficient 
and often distresses the patient. 

3. The method is unreliable, even in the hands of the 
experienced and must often be supplemented by oral in- 
sufflation. 

4. The addition of an anaesthetic by mouth in addition 
to that in situ in the rectum is more than ordinarily danger- 
ous, as we do not know what part of the latter will be 
suddenly absorbed. 

5. Distention of the rectum is prone to occur. 

6. It is undesirable in cases where the Trendelenburg 



174 ANAESTHESIA 

position is used (Fig. 18), as the injection has a tendency 
to force its way up the gut by gravity. 

7. Injections which are producing untoward effects 
frequently cannot be recovered. We doubt the possibility 
of completely irrigating the colon at will. 

8. Ulcerations of the colon and operations about the 
lower gut positively contraindicate the use of this method. 

9. The respiration may form a vicious circle, i.e., the 
more ether absorbed the more shallow the respirations are 
likely to become ; the more shallow the respirations the more 
ether accumulates in the circulation. 

10. Since the ether which is not broken up by the body 
tissues must be excreted by the lungs, we doubt the effi- 
ciency of this method in pulmonary tuberculosis. 

11. Ninety per cent, of the injections into the rectum 
find their way to the csecum by virtue of reverse peristal- 
sis. Can we recover such injections at will? 

12. Cases which present respiratory obstruction, obese 
individuals, goitre cases, etc., would appear to contrain- 
dicate this method, as such obstruction interferes with our 
chief safety valve, the freedom of the respiration. 

13. Emergency cases necessarily lacking the proper 
preliminary perparation are unsuited to this method. 

14. The untoward effects of morphine in cases having 
received a rectal injection of a solution of ether are more 
difficult to combat. 

THE DIRECT METHOD OF ANESTHETIZATION 

BY INTRAVENOUS ANAESTHESIA 
Intravenous anaesthesia is that type of anaesthesia in 
which we introduce into the circulation of the patient, by 
way of a convenient vein, a solution which contains ether. 



ETHER ANESTHESIA 175 

The strength of this solution varies from 5 to 7 per cent. 
The amount of the solution administered depends upon the 
duration of the anaesthesia. This amount is from 500 to 
3500 cc., 1000 cc. an hour being the average. The solution is 
given continuously, no accumulative action being permitted. 
We do not, as is the case with rectal anaesthesia, give a dose 
and trust to the patient to absorb it or excrete it according 
to our expectations, depending upon enemas to undo mis- 
chief after it has occurred. When one ceases to adminis- 
ter the intravenous solution, the patient " comes out " at 
once. The control is delicate and free from many of the 
complications which one is prone to meet in insufflation 
methods. 

We speak of intravenous anaesthesia as the direct 
method of anaesthesia because by this method we do not 
require the assistance of an intermediary system, such as 
the respiratory or the gastro-intestinal to assist us in our 
anesthetization. We place our anaesthetizing agent 
directly into the blood stream, through which medium it 
presumably acts upon the central nervous system. From 
the point of view of the anaesthetic, then, the method is 
direct. 

From the point of view of the anaesthetist, however, the 
matter is not so simple. The proper introduction of the 
solution implies: (1) satisfactory local anaesthesia for the 
isolation of the vein of introduction ; ( 2 ) a surgical opera- 
tion (the introduction of the cannula) . 

The speedy, skillful and painless administration of an 
intravenous injection implies familiarity with surgical tech- 
nic. Such a procedure requires perfect asepsis and dex- 
terity bred of experience. While the average anaesthetist 
might succeed in finding a vein in most cases and in success- 



176 ANAESTHESIA 

fully introducing a cannula in a smaller number, the 
chances of his doing so rapidly and painlessly would be less. 

This type of anaesthesia may be classed as an anaesthetic 
feat and, while most attractive in many of its aspects, will 
never achieve a broad practicability. It will be of interest, 
however, to consider the method and to become familiar 
with the essentials of the technic. 

Apparatus. — 1. Accessories for local anaesthesia (see 
page 257). 

2. Instruments for isolating vein. 

3. Apparatus by means of which the solution is deliv- 
ered to the patient. 

4. The solution administered. 

5. Apparatus for maintaining free respiration. 

1. The accessories for the production of local anaesthe- 
sia consist of a proper syringe, needles and solution. A 
detailed description of these various elements will be found 
under the consideration of local anaesthesia, page 257. 

2. The instruments necessary for the isolation of the 
vein consist of a scalpel, two haemostats, blunt pointed scis- 
sors, ordinary forceps and a pair of small artery forceps. 

3. Apparatus for the intravenous solution proper con- 
sists of: 

(a) A reservoir, preferably glass, having a capacity of 
2000 cc. with an outlet in the bottom. 

( b ) Tubing whose proximal end is attached to the res- 
ervoir and whose distal end terminates in a small cannula, 
which is to be introduced into the vein. 

(c) An arrangement whereby one can readily and con- 
stantly estimate the amount and rate of flow of the solution 
into the vein is essential. In the apparatus shown in Fig. 
92, this is done by means of a specially constructed glass 



ETHER ANAESTHESIA 



177 



globe through which the solution is made to flow on its 
way from the reservoir to the cannula. This globe, known 
as a dropper, is an indispensable feature of the apparatus, 
for the rate of flow of the solution, about 16 cc. per minute, 
must be constantly indicated. The action of the dropper 
is as follows : When the solution is 
flowing, it enters the upper part of 
the globe in the form of a spray or 
drop through a small, nipple-like 
projection. This is allowed to col- 
lect in the lower half of the globe, 
the control being established by a 
clip attached to the distal tubing. 
The constancy with which this level 
is kept in the presence of a continu- 
ous flow through the nipple indi- 
cates the flow to the patient. 

4. The solution, a 5 to 7.5 per 
cent, solution of ether in sterile 
Ringlers solution (a solution con- 
taining sodium, potassium and cal- 
cium chloride), or in ordinary 
normal saline, at a temperature of 
85° F. 

5. A pharyngeal tube. 
The Administration. — It is 

quite essential that the usual pre- 
liminary treatment, as indicated in the section covering the 
control of the period of excitement, page 24, be carried out. 
The preliminary visit is especially valuable for the bene- 
ficial effect of suggestive therapeutics. The patient must 
be brought into the operating room and placed on the 

12 




&S> 



Fig. 92. — Intravenous apparatus. 



178 ANAESTHESIA 

table half an hour before the time set for the operation. 
Incidentally this means that the operating room must be 
set and the anaesthetist on hand some three-quarters of an 
hour to an hour before the time set for operation. 

When the patient has been placed on the table, a hypo- 
dermic of morphine grs. % and atropine 1/100 and scopo- 
lamine 1/100 is administered. The arm to receive the 
solution is strapped to the support upon which it rests. 
The veins of the forearm are made to stand out promi- 
nently by digital pressure above the elbow. A space as big 
as a dime is injected with novocaine .5 per cent. The skin 
is incised and the vein exposed and dissected out. While 
this procedure is being accomplished, the reservoir is filled 
with the solution and placed on the stand 8 feet above the 
floor. The vein having been isolated, a ligature tied dis- 
tally and an untied ligature placed proximally to the open- 
ing made therein, the cannula with the solution flowing is 
gently introduced and secured by the loose ligature, which 
is now tied with one knot. A large gauze pack is now 
placed over the field and strapped to the arm with adhesive 
plaster. 

We may then devote our attention to the indicator 
and the patient. 

The solution is allowed to flow slowly into the vein. 
The patient soon passes into a quiet sleep with little or no 
excitement. The transition from consciousness to the stage 
of maintenance is indeed so quiet that one would be led to 
suspect that anaesthesia was not present were it not for the 
loss of the lid and eye reflexes. The airway must be patent 
at all times. This is best accomplished by the introduction 
of the Connell tube as soon as the pharyngeal reflexes have 
disappeared. Anaesthesia is increased (the level of main- 



ETHER ANAESTHESIA 179 

tenance raised) by increasing the flow of the solution, the 
patient is allowed to " come out " (the level of mainte- 
nance is lowered) by stopping the flow. It is more satis- 
factory to keep up a continuous flow than to give the solu- 
tion intermittently, since the patient recovers promptly 
upon the cessation of the flow. The amount of the solution 
usually consumed in an hour is 1000 cc. 

Post-Operative Treatment. — The wound in the arm 
should be closed with a straight needle. It may then be 
wiped with iodine solution or carbon tetrachloride in thy- 
mol (50 per cent, solution), and the dressing applied. 

The patient should be placed in the semi-Fowler posi- 
tion ( Fig. 122 ) , and he should be turned every hour to over- 
come the tendency to pulmonary oedema and the formation 
of spots resembling bruises in the loose, fatty tissue of the 
back and buttocks. 

The Advantages of the Method 

Ideal control of the administration. 

Not dependent upon the rate or the depth of the 
respiration. 

The minimum amount of the anaesthetic is employed. 

There is little or no cumulative action. 

The technic is sufficiently complicated to exclude 
thoughtless experimentation. 

The Disadvantages 

The general anaesthetic must be preceded by an opera- 
tion under local anaesthesia. 

The preliminaries to the administration of the anaes- 
thetic per se involve a loss of much time and, from this 



180 ANAESTHESIA 

point of view, the method is impractical as a routine in the 
large hospital. 

The proper administration implies familiarity with the 
surgical technic required. 

The blood pressure is raised. 

The bleeding is increased and the fluid has a tendency 
to collect in the abdomen. 

It is an open question as to the harm done by the injec- 
tion of a normal saline solution in the blood stream of a 
healthy individual. 

The possibility of septic thrombosis must be considered. 

There is a tendency to pulmonary oedema and spots, 
resembling bruises, frequently appear on the back and 
buttocks. 



CHAPTER V 
ETHYL CHLORIDE 

Ethyl chloride, or sweet spirits of salt, was discovered 
by Florens in 1847. It is a colorless liquid, very volatile 
and has a pungent, ethereal odor. It boils at 12.5 C. 

Ethyl chloride is used for general anaesthesia as well as 
for local anaesthesia. (See page 249.) 

While ethyl chloride has been frequently employed as 
a general anaesthetic throughout the stages of induction, 
maintenance and recovery, its use as the sole anaesthetic in 
such a complete ancesthesia should be discouraged. This 
is because of the narrow margin of safety between a stage 
of satisfactory maintenance (complete muscular relaxa- 
tion) and the lethal dose or the dose which may kill. Col- 
lapse is more liable to follow ethyl chloride than any other 
anaesthetic. 

From a practical point of view then the administration 
of this anaesthetic is limited to : ( 1 ) the induction of anaes- 
thesia (as a preliminary to ether anaesthesia) ; (2) incom- 
plete ancesthesia ( that type of anaesthesia without the stage 
of maintenance) . 

The administration of ethyl chloride as a preliminary 
to ether, and its use alone for short operations, is but a 
matter of degree. With the former our object is to destroy 
consciousness; with the latter we go a step further and 
approach the period of relaxation. 

Ethyl chloride is frequently used as a substitute for 
N 2 0. Portability and cheapness are offered as reasons for 
this. In view of the unquestionably greater safety of N 2 0, 
however, such a procedure is entirely unjustifiable. The 
situation is well put by Thomas D. Luke, who says " The 

181 



182 ANAESTHESIA 

idea has got about among a large number of both the medi- 
cal and dental profession that ethyl chloride is a sort of a 
glorified N 2 0, which one may carry about in one's waist- 
coat pocket and administer to all and sundry, without any 
special precaution or skill on the part of the administra- 
tor . . . Nothing further from the facts could be imagined 



Fig. 93. Fig. 94. 



«r 





Chloroform Squi 

FOR ANL5THESK 



MJUTBB & SONS.KT 

'"**<«M»SrS TO THt Wi we** <""£*; 




SO CMS. 

Chloroform, Sqsi 

FOR ANjtSr«C$l» 




Fig. 93. — The tin can container should not be used owing to the danger of confusion with the 

ordinary ether can. 
Fig. 94. — Ethyl chloride container, spray. 



. . . Its highly toxic character and the danger due to 
the great rapidity of its action should be fully recognized 
as well as its admirable properties as an adjuvant to chloro- 
form and ether." Dr. Luke follows his remarks with a 
report of twenty-three deaths from ethyl chloride in the 
short span of five years. 



ETHYL CHLORIDE 183 

The administration of ethyl chloride is often followed 
by headache, nausea and vomiting. These symptoms may 
appear immediately after recovery or be delayed for five 
or six hours. 

When ethyl chloride is administered, the consciousness 
is rapidly lost as with N 2 0. Its effects are best seen with 
a closed apparatus, as with ether. In overdose it kills 
quickly, as does chloroform. 

A cork or some other mouth prop must be placed 
between the teeth before the administration is begun, for 
masseteric spasm is prone to occur. 

When a closed apparatus is used the dose should not 
exceed 1.5 cc. for children and 3 to 4 cc. for adults. This 
dose should be given slowly and cautiously. 

When open or semi-open methods are used, the dose 
may be increased. 

Ethyl chloride, owing to its very great tendency to 
evaporate, is marketed in special glass containers. (See 
Fig. 94.) The delivery from some containers is controlled 
by a spring lever applied to the vent, in others by a gas- 
tight screw cap. 

The Administration of Ethyl Chloride as a Pre- 
liminary to Ether Anesthesia or Alone for the 
Purpose of Securing Incomplete Anesthesia 

Apparatus. — The semi-open drop mask, as described 
on page 128, or a closed apparatus such as described on 
page 134. 

When the semi-open method is employed a much larger 
quantity of the drug will be required. 

Before starting the anaesthetic a mouth prop is placed 
between the teeth of the patient ; the mask is then arranged 
as in Fig. 69 or Fig. 71, and the patient is instructed to 



184 ANESTHESIA 

count out loud. Ethyl chloride is carefully sprayed upon 
the mask. The administration is continued until conscious- 
ness is lost, when ether in the form of a drop or spray is 
resorted to. 

The effects obtainable by this method are not nearly 
as satisfactory as those which may be secured by the em- 
ployment of a closed method. Where the latter is em- 
ployed, the rebreathing bag is filled with the patient's 
expirations. He is then instructed to breathe naturally to 
and fro. As he does so, ethyl chloride is sprayed into the 
apparatus through some convenient vent; either into the 
bag proper, or into the evaporating mediums, gauze, wire 
screen, or whatever it may be. The drug is added slowly, 
not more than 4 cc. in all being used. 

Free air should be administered upon the first evidence 
of stertor. 

When ethyl chloride is given per se to produce incom- 
plete anaesthesia, it should not be pushed to a loss of the 
corneal reflex and a dilated pupil. An absent lid reflex, 
page 103, deep, involuntary respirations and absence of 
muscular excitement being all that is desired. 

When employed as a preliminary to ether, we have 
attained our object when consciousness is lost and the 
pharyngeal reflex has been rendered somewhat less sensi- 
tive to the odor of ether. 

The loss of consciousness when ethyl chloride is used 
for induction is not so rapid or so pleasant as when JX" 2 
is used. It is, however, more speedy and more grateful 
to the patient than is ether alone. 

The dangers of this anaesthetic are twofold: From 
overdose ; from asphyxia, secondary to spasm occurring in 
the respiratory tract. 

The proper anticipation of these difficuties will fore- 
stall untoward results. 



CHAPTER VI 

CHLOROFORM 

Chloroform was first used as an anaesthetic by Sir 
James Simpson in 1847, some months after the announce- 
ment of the discovery of ethyl chloride by Florens. 

Chloroform is a colorless liquid with a sweet but burn- 
ing taste, and possessed of an ethereal odor. The boiling 
point is 61.2 C. 

GENERAL CONSIDERATIONS 

Since its discovery chloroform has been the favorite 
anaesthetic of continental Europe. Ether, however, has 
found greater favor in this country, more particularly in 
the large cities. In country practices and small towns in 
the L T nited States, chloroform is still extensively employed. 

With chloroform the stage of induction is usually free 
from excitement; the stage of maintenance is quiet and 
characterized by tranquil breathing and complete relaxa- 
tion. The stage of recovery is comparatively brief and the 
after-effects of the anaesthetic are usually conspicuous by 
their absence. 

Chloroform, however, unlike ether, is a distinct pro- 
toplasmic poison. Chloroform kills quickly in overdose 
(in a concentration of 5 per cent, or more) . Chloroform is 
most dangerous during the stage of induction, at which 
time it is most commonly used. 

As a protoplasmic poison, the evil effects of chloro- 
form frequently do not become evident until some time 
after the administration. Such late effects are known as 
" delayed chloroform poisoning." This condition of de- 

185 



186 ANAESTHESIA 

layed chloroform poisoning is now well recognized. The 
degenerative effects which take place closely resemble those 
found in the liver and kidneys of eclamptic cases. Numer- 
ous investigators have pointed out these lesions. We quote 
the following from a paper by Drs. E. B. Cragin and E. T. 
Hull of the Sloane Maternity Hospital: 

" Recent studies of the pathologic changes produced 
by eclampsia, delayed chloroform poisoning and chloro- 
form anaesthesia have shown a striking similarity in the 
findings in all three conditions." 

The pathologic picture in each is that of congestion, 
hemorrhage, degeneration and necrosis. Our knowledge 
of the pathology of eclampsia is of comparatively recent 
date, but thanks to the work of Jurgens, Schmorl, 
Williams, Ewing, Welch and others, the lesions are now 
well recognized and generally accepted. 

Delayed chloroform poisoning as such has been fre- 
quently recognized and carefully studied, both clinically 
and pathologically, for the last twenty years. Many writers 
have reported series of fatal cases, all showing symptoms 
and lesions which are now recognized as typical of the con- 
dition. A number of these deaths occurred after only 
twenty or thirty minutes of anaesthesia, untoward symptoms 
developing a few hours to a few days after the administra- 
tion. The symptoms include progressive weakness, pallor 
or cyanosis, restlessness, vomiting, delirium, convulsions, 
stupor, coma and death. The organs principally affected 
are the liver and kidneys. The former is yellow and fatty, 
with hemorrhages often under the capsule and through- 
out its substance. The typical picture is that of a central 
necrosis. The cells about the central vein disappear, leaving 
only a mass of granular material which shows neither nuclei 



CHLOROFORM 187 

nor cell outline. Nearer the periphery of the lobule is a zone 
of swollen cells, which have undergone hyaline and fatty 
degeneration. A few normal liver cells may remain at the 
periphery. The kidneys are swollen, markedly congested, 
with occasional hemorrhages under the capsule, about the 
tubules, and in the pelvis. The cortex is thickened, the 
markings indistinct. Microscopically the cells of the 
tubules are greatly swollen, granular, and loaded with fat. 
The lumen is filled with granular material, fat globules 
and coagulated serum. The heart muscle often shows 
some fatty degeneration. The changes are generally con- 
sidered to be more profound in the liver, though some ob- 
servers have found the kidney degeneration even more 
marked. 

The reports of these cases of delayed chloroform 
poisoning with their pathologic findings led naturally to 
a study of the lesions produced by chloroform anaesthesia. 
Many animals were used in these experiments, most often 
dogs, rabbits and guinea-pigs. These studies were exhaus- 
tive and include the work of Lengemann, Ostertag, Stiles 
and McDonald, Stassman and others, together with the 
more recent work of Howland and Whipple. The most 
striking result of these studies was the extent of the degen- 
eration and necrosis found in the liver and kidney after 
chloroform anaesthesia of a short duration. 

It has been found that characteristic lesions are regu- 
larly produced, varying in degree with the duration and 
depth of anaesthesia, and also with idiosyncrasy. Thus 
after thirty minutes to one hour anaesthesia with chloro- 
form, the centres of the lobules of the liver show conges- 
tion with granular and fatty degeneration, the innermost 
cells being necrotic, their nuclei not taking the stain and the 



188 ANAESTHESIA 

protoplasm being deeply stained pink with eosin. With 
more prolonged action the changes approach those found 
in delayed chloroform poisoning in man. The liver ap- 
pears yellow and fatty with scattered hemorrhages. The 
cells about the centres of the lobules are entirely necrotic, 
a granular mass remaining. Outside of this is an area of 
cells which have undergone hyaline and fatty degenera- 
tion, with normal cells at the periphery. In some cases 
the liver cells have almost entirely disappeared with only 
a few scattered living cells in the portal spaces. In the 
kidney, chloroform anaesthesia causes a marked congestion 
with a cloudy swelling and occasionally hemorrhages into 
the parenchyma. The cells of the tubules are swollen and 
granular, occluding most of the lumen ; in other places they 
have disappeared entirely. Fatty degeneration is present 
and in many cases pronounced. The heart muscle may be 
pale and show fat droplets in its fibres. Hemorrhages 
occur throughout the body, particularly in the serous mem- 
branes, and in the intestinal and stomach mucosa. 

Howland and others were able, almost at will, by con- 
tinuing the anaesthesia to produce delayed chloroform 
poisoning in dogs, with symptoms and lesions correspond- 
ing in detail with those of delayed chloroform poisoning 
in man. Thus we find in these three conditions, eclampsia, 
delayed chloroform poisoning in man and chloroform anaes- 
thesia in animals, many similarities. Pathologically there 
is central necrosis, parenchymatous and fatty degeneration 
in the liver ; congestion, parenchymatous and fatty degen- 
eration in the tubules of the kidney and a tendency to 
hemorrhages throughout the body. Clinically in delayed 
chloroform poisoning and in eclampsia there are vomiting, 
jaundice, delirium, convulsions and coma. 



CHLOROFORM 189 

Does ether produce lesions in the liver and kidneys simi- 
lar to chloroform? Some work has already been done along 
this line, notably by Bandler, Lengemann and Leppmann, 
and it was partly to confirm scattered observations on this 
subject that a further study of ether anaesthesia was 
undertaken. 

In our experience six mongrel dogs of medium size 
were given ether by inhalation from an open cone. They 
were killed with ether forty-eight hours after the last anaes- 
thesia and autopsied at once. Sufficient ether was given 
to produce complete muscular relaxation with loss of 
corneal reflex. 

In none of these animals could any necrosis in any of 
the parenchyma be found. In the lungs occasional small 
areas of a deeper red than the surrounding substance, con- 
taining an increase in the amount of blood on section, 
showed congestion. The heart muscle in each dog was 
found to be of normal color, striations distinct, no appar- 
ent increase in fat. 

There were no hemorrhages in the mucosa of the 
stomach and intestines. 

The livers were of a good color throughout, the vessels 
in a few places standing out a brighter red than the sur- 
rounding structure. The yellow appearance was entirely 
lacking, the cells throughout preserved their outlines with 
contents intact. There was no suggestion of necrosis at 
any point. The protoplasm was somewhat granular and 
small droplets of fat were found in the cells about the 
central veins and in the portal spaces. This fat was only 
slightly in excess of that in the controls. 

The kidneys were of normal size, capsule not adherent, 
cortex not thickened, markings distinct. Microscopically 



190 ANAESTHESIA 

the cells of the tubules were well preserved throughout; 
their outlines were distinct, the nuclei staining sharply, 
the protoplasm granular, the tubules containing in some 
places some granular material. Fat globules were present 
in a few of the straight tubules and in the lining cells. 
This condition seemed no more than is normally found, 
and no more marked than in the controls taken. 

No pathologic changes could be found in any of the 
sections of pancreas and spleen. These facts seem to 
demonstrate that in animals, at least, ether produces prac- 
tically little effect on the liver and kidneys as compared 
with the very marked changes in these organs produced by 
chloroform, and, while it may be argued that this compari- 
son has been demonstrated only in animals, the similarity 
between the lesions of delayed chloroform poisoning in 
man and chloroform anaesthesia in animals makes it appear 
more than probable that reasoning as to the effect of ether 
on the liver and kidney of man, from the lesions produced 
by ether in animals, is entirely justified. 

The foregoing facts lead to the conclusions arrived at 
by the Committee on Anaesthesia of the American Medical 
Association, June 15th, 1912: 

" 1. The use of chloroform as the anaesthetic for major 
operations is no longer justifiable. Scientific investigation 
and clinical experience agree in demonstrating that necro- 
sis of the liver ( ' delayed chloroform poisoning ' ) follows 
in a by no means inconsiderable percentage of cases. The 
mode of causation of this sequel is unknown. There are 
therefore no precautions that can be intelligently taken 
against it. Accordingly the surgeon whose patient dies 
in this manner a day or two after operation must face the 
responsibility of having knowingly taken an unnecessary 



CHLOROFORM 191 

chance — and lost. We see no reason to believe that in 
respect to toxicity there is more than a slight quantitative 
difference between chloroform alone and such chloroform 
mixtures as A. C. E., anesthol, etc. 

" 2. For minor operations also the use of chloroform 
should cease. In general it may advantageously be re- 
placed by nitrous oxide, or nitrous oxide-oxygen. It is a 
mistake to think that a fatality under anaesthesia is neces- 
sarily due to an unusually large administration of the 
anaesthetic. A previous condition of suffering or anxiety, 
or a prolongation of the stage of anaesthesia excitement 
renders a subject who would otherwise be able to resist a 
large dosage, liable to collapse even under a small dosage. 
The practical importance of avoiding so far as possible 
all anxiety and pain has been demonstrated on the clin- 
ical side by Crile, and experimentally by Henderson. It 
is noteworthy that Levy (with Cushny) has recently 
demonstrated that in cats a sudden heart failure (fibrilla- 
tion) is induced by a period of light chloroform anaesthe- 
sia, while this form of death is not inducible by deep 
anaesthesia. Risks of this sort are far greater with chloro- 
form than with ether, and greater with ether than with 
nitrous oxide. As they cannot be foreseen, they cannot be 
avoided, except by replacing a dangerous anaesthetic by 
a safe one. 

" 3. Chloroform is sometimes found convenient for initi- 
ating anaesthesia in alcoholics or other difficult subjects. 
As a means of avoiding the ill effects of a prolonged period 
of ether excitement the temporary employment of chloro- 
form for this purpose is perhaps sometimes the lesser of 
two evils. It is justifiable only when nitrous oxide is not 
available. If chloroform is to be so used, it should be 
given as soon as it is evident that the patient will not go 



192 ANAESTHESIA 

under ether readily. Unless the change to chloroform is 
made early it should not be made at all. We wish espe- 
cially to emphasize the point that chloroform should never 
under any circumstances be administered after a pro- 
longed period (10 or 15 minutes or more) of ether excite- 
ment. Even a small administration of chloroform is then 
peculiarly liable to induce respiratory or cardiac death. 
As soon as full anaesthesia is attained ether should be 
substituted." 

It has been argued that the evil effects of chloroform are 
largely due to impurities found in the drug; these impuri- 
ties depending upon faulty preparation or exposure to 
light and air. If such toxic impurities are so constantly 
present as to result in the common findings of a large num- 
ber of investigators, it would seem that the end result is 
the same as though the evil lay in the drug itself. We can 
scarcely hope to convince all users of chloroform of the 
danger of their position and urge upon them a favorite 
preparation of our own. If chloroform is shown to be con- 
sistently poisonous we had best forego the pleasure of its 
free usage and confine ourselves to an anaesthetic which is 
safer, though somewhat more difficult of manipulation. 

We who have become accustomed to chloroform will 
be prone to yield ourselves to its charms and to feel that 
because clinical distress seldom appears, pathological 
damage has not occurred. We will recall particularly our 
rather extensive experience in obstetrical cases, the delight- 
ful and efficient anaesthesia which we have so often ob- 
tained, the freedom from excitement in induction and the 
absence of symptoms upon recovery. We will recall the 
many instances in which we have anaesthetized children 
large and small. We are prone to smile when the pathol- 



CHLOROFORM 193 

ogist condemns our most valuable agent " chloroform." 
We will not abandon chloroform but we will use it less 
frequently and with more respect. 

Those of us who are now receiving our obstetrical train- 
ing will find little difficulty in getting along without this 
valuable but dangerous agent. The present generation 
brought up upon a constant diet of pathological findings 
learn to look with increasing confidence to this authority. 
We accept its dictates as our own and confidently walk 
in the light of its decisions. If we accept the conclusions 
of pathology, chloroform per se cannot be the anaesthetic 
of choice in the routine case. 

The indications which present themselves for the use of 
chloroform must be sufficiently urgent to overcome our 
aversion to its use. The chief indication is that presented 
by acute pulmonary disease where N 2 and O is not availa- 
ble, and in the control of individuals who cannot be well 
handled by ether. 

One of the most marked characteristics of chloroform 
is its tendency to bring about circulatory depression. In 
glancing over the works of Hewitt, Luke and other English 
authors, one is struck with the frequent reference to cir- 
culatory shock. We scarcely ever see a case of this nature 
where ether is the anaesthetic. The use of ether with chloro- 
form appears to reduce the likelihood of this type of shock. 
This explains in part the popularity of the well known A. 
C. E. mixture (alcohol 1, chloroform 2, ether 3). The 
alcohol of this mixture is usually omitted, the result being 
a C. E. mixture. 

The C. E. mixture is so much safer than the chloroform 
per se that it has largely supplanted the employment of 
the latter. 

13 



194 ANAESTHESIA 

Containers. — Since chloroform deteriorates upon ex- 
posure to air it is safer not to use a sample which has been 
opened (Fig. 93). With this fact in mind manufactories 
are now putting out ampules and bottles sufficient for one 
administration. Bottles containing one ounce are inexpen- 
sive and satisfactory. If the solution is not all used the 
residue should be sent to the pharmacy for the preparation 
of chloroform liniment. 

The Administration. — Since the addition of ether to 
the chloroform reduces the likelihood of circulatory depres- 
sion and improves the quality of the respiration we have 
practically abandoned the use of chloroform per se. 

Ether may be given mixed with chloroform in the pro- 
portion of ether-parts 3, chloroform-parts 2, or the drugs 
may be given alternately by the drop method. A few 
drops of chloroform being followed by a somewhat larger 
amount of ether. Where one is desirous of obtaining the 
effects of chloroform, more particularly for the stage of 
induction, the contents of an ounce bottle of chloroform 
freshly opened is mixed with one and one-half bottles of 
ether (the empty chloroform bottle being the measure) . 

As the stage of maintenance is approached, ether is 
added to the container, one ounce at a time. By the time 
the stage of maintenance has been entered upon the amount 
of chloroform present in the mixture will be so small as to 
be practically negligible. 

Apparatus. — When the C. E. mixture is employed it 
may be administered to the patient by: (a) the drop 
method ; ( b ) the vapor method. 

(a) When chloroform alone is used there should be no 
air restriction whatever. For this reason the use of the 
semi-open method and the closed method should not be 



CHLOROFORM 195 

tolerated. The open drop mask, as described on page 122, 
may be employed. If chloroform alone is used the mask 
should not be permitted to rest against the face. Where 
the C. E. mixture is the anaesthetic, however, the mask may 
be used, as in the case of the open drop method of ether 
administration. One should always remember that one is 
administering chloroform and that it is dangerous to soak 
the mask as may be safely done in the case of ether per se. 
The mixture should be added cautiously drop by drop, the 
signs of anaesthesia being our index as to whether we should 
push or decrease the administration. 

( b ) The vapor method is a very convenient and effec- 
tive method of administering the C. E. mixture. Oxygen 
is preferable to air as a means of producing the vapor. 
The same care should be exercised as in the case of the 
drop method. As anaesthesia progresses ether may be 
added to the reservoir, thereby reducing the risk of chloro- 
form complications. Chloroform should never be given 
near a naked flame. A product known as phosgen gas is 
formed which may seriously effect not only the patient 
but the operator and assistants as well. 

The Causes of Death in Chloroform Anesthesia 

In the stage of induction chloroform deaths occur as 
follows : 

(a) Spasm of the respiration occurs. The anaesthetist 
continues to drop the chloroform upon the mask. A large 
amount of chloroform thus accumulates. Following the 
relief of the spasm, spontaneous or artificial, the patient 
breathes deeply. A lethal dose of chloroform is carried 
to the heart muscle, which, weakened by the previous res- 



196 ANESTHESIA 

piratory spasm, suddenly and permanently dilates. This 
is the usual cause of death of the large, alcoholic and 
athletic individual. 

(b) Vagus inhibition, causing paralysis of the heart 
muscle, sometimes occurs in high strung, neurotic in- 
dividuals. 

In the stage of maintenance chloroform deaths may 
occur as follows: 

(a) By the elevation of the head and shoulders syncope 
may result, which in turn may develop into definite circu- 
latory shock and cessation of the respiration. 

( b ) By simple overdose. 

In the stage of recovery death may result from: 

(a) Progressive acidosis secondary to an acute sep- 
ticaemia or from unrecognized diabetes. 

Post-operative death occurs as a result of extensive 
protoplasmic poisoning effecting chiefly the liver and the 
kidneys. 

Chloroform fatalities are not likely to occur if the 
following suggestions are adhered to: 

If it is excluded in cases of acute septicaemia, acidosis 
and eclampsia. If it is invariably used with ether and not 
alone. 

If the prone position is always adhered to. ( Even the 
position advised for upper abdominal closure, page 43, 
should be avoided) . 

If fresh, newly opened specimens of chloroform are 
used. 

If the mask is taken off the face during masseteric 
spasm. 

If the corneal reflex is always retained, and a lustreless, 
dilated, fixed pupil never permitted. 

If the rhythm of the respiration is maintained, and the 



CHLOROFORM 197 

administration changed to straight ether upon the first 
sign of inexplicable shallowness or irregularity. 

When the heart stops in chloroform it usually does so 
as a permanently damaged organ. Its dilation is toxic 
rather than mechanical, hence the difficulty of resuscitation. 
The blood in the coronary arteries must be squeezed out 
manually to relieve the condition. Massage of the heart 
through the diaphragm even though it calls for a special 
laparotomy should be done; for death under these circum- 
stances is a most dreadful thing. Who would refuse a 
laparotomy upon himself in such an extremity? Trans- 
pleural pericardiotomy for massage of the heart may also 
be practised. There is some hope of success even though 
the heart has ceased to beat for ten minutes. 

Lieb has suggested that the radial artery be imme- 
diately exposed. A cannula delivering the saline ordi- 
narily employed for intravenous injections, at a height of 
four feet above the artery is introduced and when the flow 
into the artery actually begins, inject directly through the 
rubber tubing next to the cannula ten minims of adrenalin. 
This dose may be repeated four or five times. 

Artificial respiration by negative and by positive ven- 
tilation should always be done (page 91). 

The Signs of Anesthesia when the C. E. Mixture is 
the Anaesthetic 

When chloroform is used alone a condition of pseudo- 
relaxation or natural sleep is likely to follow especially in 
children. When the C. E. mixture is employed this does 
not occur. 

The patient must invariably be anaesthetized in the 
prone position. 



198 ANAESTHESIA 

Induction. — Excitement much less than when ether is 
used alone. 

Rigidity of shorter duration. 

Relaxation more easily accomplished. 

Respiration regular, moderately deep, increased in 
rapidity, becoming stertorous. More shallow than with 
ether alone. 

Eyes. — Globes rolling vertically or horizontally (as in 
ether). Pupils: A pin-point pupil is suggestive of light 
anaesthesia, otherwise pupils are like ether pupils. Corneal 
reflex : Active as in ether. Light reflex : Active as in ether. 

Color. — Pallor characteristics of chloroform per se. 
With the C. E. mixture the color approaches that of ether. 
Pallor is suggestive of circulatory shock. 

Relaxation. — Lid relaxation somewhat sooner than 
with ether. Masseteric relaxation somewhat sooner than 
with ether. If spasm occurs the anaesthetic should be dis- 
continued at once and not resumed until breathing is free. 

Pulse. — The quality of the pulse must be carefully 
observed. Circulatory depression will give a small pulse 
of poor tension accompanied by pallor of the face. 

Maintenanc e. — Respiration. — Moderate stertor. 
More shallow and not so rapid as with ether alone. Regular 
rhythm must be preserved. The regularity of the repiration 
is the most important sign of chloroform anaesthesia, as 
failure of the respiration invariably precedes cardiac f ailure. 

Color. — Pale. Cyanosis must not be tolerated. If the 
percentage of ether used be increased a better color will 
result. 

Eyes. — Globes fixed, lustrous. Pupils about normal or 
slightly enlarged. Light reflex present, sluggish. Corneal 
reflex sluggish; should not be obliterated. 



CHLOROFORM 199 

Relaxation. — Lid reflex absent. Masseteric relaxa- 
tion present. General muscular relaxation characteristic. 

Pulse. — A valuable guide. Its tension, size and rapid- 
ity should be constantly observed. As a symptom of anaes- 
thesia per se it is more important than in ether anaesthesia. 

Recovery. — The rapidity of the return of the reflexes 
and later the return of consciousness will depend upon the 
level at which the stage of maintenance was carried and 
upon the length of the anaesthesia. 

Respiration. — More shallow than with ether. 

Color. — Pallor normal. 

Eyes. — As with ether. 

Muscles. — Generally relaxed. 

Pulse. — Everything else being equal, not so good as in 
ether anaesthesia. Because of its action as protoplasmic poi- 
son, chloroform frequently gives rise to serious after-sick- 
ness, especially if the administration has been protracted. 
Where the administration is brief and the dose small, the 
after-effects are usually conspicuous by their absence. 

Broadly speaking we may say that chloroform alone 
and chloroform given with ether is contraindicated in all 
cases, except: (a) Acute pulmonary disease, pneumonia, 
etc., where N 2 cannot be had. (6) Acute obstruction of 
respiratory tract, Ludwig's angina, etc. (c) As a prelim- 
inary to ether anaesthesia, when N 2 is not available, (d) 
For cases in which the actual cautery is used upon the face 
or in the mouth. 

Oral Insufflation of Chloroform Vapor 
If there is a time when chloroform is justifiable it is 
to maintain anaesthesia in nose and throat operations espe- 
cially in adults. Used for this purpose it produces anaes- 
thesia which is certainly ideal. 



200 ANAESTHESIA 

An apparatus such as is shown in Fig. 81 is the one 
employed by the author and has been found entirely satis- 
factory. It consists of the so-called potato tube used for 
bacteriological cultures and an ordinary cautery bellows. 
When anaesthesia induced by closed gas ether is complete 
the mouth gag is introduced. Pure chloroform vapor is 
then used to maintain anaesthesia. The respirations are 
tranquil, the sensitive pharyngeal reflexes are completely 
under control, there is little or no mucus secreted and the 
amount of chloroform required is exceedingly small. 
Where care is employed this method is decidedly the best 
for tonsillectomies or cleft-palate operations in adults 
when the proper ether insufflation methods are not 
available. 

TO REITERATE 

Chloroform, while ideal in efficiency, is a dangerous 
poison. In the light of present-day pathology, chloroform 
should cease to be used as an anaesthetic in obstetrics. 

Combined with ether, chloroform is quite as efficient 
and less dangerous. 

Chloroform kills if pushed in the face of masseteric 
spasm. 

Delayed chloroform poisoning is a fact and argues for 
the complete replacement of the drug by safer anaesthetic 
agents. 

Chloroform, if used at all, should be taken from a 
freshly opened receptacle. 

The administration should invariably be performed in 
the prone position. 

The mortality of chloroform is variably estimated as 
1-1000, 1-3000. 



CHAPTER VII 
NITROUS OXIDE 

Nitrous oxide, laughing-gas or nitrogen monoxide, is 
prepared by heating ammonium nitrate NH 4 N0 3 , the 
result being N 2 and 2H 2 0. 

Nitrous oxide is non-irritating to the respiratory tract, 
is possessed of a sweet taste and an odor like that of burnt 
sugar. The boiling-point of liquid N 2 is - 90 C. 

Containers. — Nitrous oxide is marketed as a liquid. 
It is stored in specially made vanadium steel cylinders, 
(steel which will not shatter but will simply split) whose 
capacity varies from 25 gallons to 3200 gallons. Fig. 95 
shows various sizes of N 2 cylinders. 

The pressure of the liquid gas enclosed in the cylinder is 
about 1000 lbs. to the square inch, at room temperature. If 
the cylinders be allowed to remain against a hot radiator 
for some time there is great danger of explosion from the 
increased pressure. The gas is drawn from the cylinders 
by means of a key which opens a complex valve in the 
cylinder head. These valves must be operated cautiously 
or the gas will escape with a roar which will badly frighten 
a waiting patient. When the operator has only one hand 
free to manipulate the valve the cylinder should be pre- 
vented from rotating on its base by some such device as is 
shown on page 209, Fig. 99. If the gas does not escape 
gradually when the valve is opened, it is best to work the 
valve back and forth before further opening. Occasion- 
ally the valve becomes frozen and will not permit of an 
even escape of the gas. If such a valve is widely opened 

201 



202 



ANESTHESIA 



the pressure of the gas will suddenly blow away the ob- 
struction with a loud explosion. The freezing of valves 
in the manner just mentioned is most likely 
to occur where a constant flow from 
the cylinders is sought, or when the 
cylinders are in the 
horizontal instead 
of the vertical posi- 
t i o n. Specially de- 
signed reducing 
valves, see Fig. 
96, prevent the 
possibility of the 
valves freezing 




ills 



1200 N..0 -150 N ; -0 250 N»0 150 NjO S00 N s O 
400 Oxy. 130 Oxy. 8ft Oxy. 50 Oxy. 30 Oxy. 



Fig. 95.— Various sizes of gas and oxygen tanks. 

and give a constant, even flow of gas at any desired rate. 

Estimating the Amount of Gas in a Cylinder. — 
There is one way, and only one way, of estimating the 
amount of gas in a cylinder at any given time, and that is 
by weighing the cylinder. One will always find a label 



NITROUS OXIDE 203 

pasted on the side of the cylinder (Fig. 97), on which is 
written : 

The weight of the cylinder full of gas. 

The weight of the cylinder empty. 

The difference in these two weights represents the 
weight of the liquid N 2 in the cylinder. One ounce of 
N 2 is equal to four gallons of the gas at room temperature 
and pressure. The weight of the liquid N 2 in a full 
100-gallon cylinder is therefore 25 
ounces, or one pound nine ounces. 

The 25-gallon cylinder is in- 
tended more particularly for private 
work where the gas is desired for 
induction only, the weight of the 
cylinder and contents being 2 pounds. 

The 100-gallon cylinder is the 
size ordinarily used. This type of 
cylinder is somewhat more cumber- 
some, but more dependable than is FlG - 96 -- Reduci ^ valve - 
the smaller size. The weight of the 100-gallon cylinder 
with contents is between eight and nine pounds. 

The 250-gallon cylinders are intended for hospital use 
where the gas is freely employed not only for inducing 
anaesthesia but for maintaining it as well. 

Some hospitals have become so enthusiastic over gas 
oxygen anaesthesia that they have installed small plants 
for the manufacture of the gas. At the Lakeside Hospital, 
Cleveland, a plant is in operation which supplies all the 
nitrous oxide used in the institution. Fig. 98 is a schematic 
drawing of this plant. Briefly the details of the manufac- 
ture are as follows : 

Ammonium nitrate in quantities of forty pounds at a 




204 



ANAESTHESIA 



time is put into each of two aluminum retorts (a double sys- 
tem is used so that the plant will not be completely dis- 
abled in case of accident). This is heated to 400 degrees. 
The ammonium nitrate then breaks down into N 2 and 
H 2 0, which mixture is cooled by a condensing coil and 
lead into wash bottles containing potassium permanganate. 




^ mm _». .... -f . jr. ?v a : » 

Fig. 97. — Label on N2O cylinder. 



This treatment removes the oxides. The gas is then fed 
into the bottom of so-called towers filled with coke. From 
the roof of these towers sodium hydrate is constantly 
sprayed. This treatment removes any HN0 3 which may 
be present. From the top of the tower the gas is conveyed 
once more to wash bottles containing sulphuric acid. This 
treatment removes any free alkali. The gas is then washed 



o s 







206 ANESTHESIA 

by passing through fresh water and finally led to an ordi- 
nary gasometer. When a sufficient bulk of gas has here 
collected it is compressed by a pump either to liquefaction 
(for storage in small cylinders at a pressure of 1500 lbs. 
to the square inch) , or for storage in large tanks at a com- 
paratively low pressure, about 100 lbs., which is again re- 
duced to about five pounds when it is piped to the operat- 
ing room to be used as desired. When the gas reaches the 
operating room it passes through a gas meter which checks 
the amount consumed. From the meter it is conveyed 
through heavy rubber tubing to the apparatus which regu- 
lates the immediate flow to the face piece. 

The cost of N 2 is about three and one-half cents a gal- 
lon. In the 25 gallon tanks it costs a little more; 
when in 250-gallon cylinders or larger the cost is somewhat 
less. The actual cost of manufacturing the gas is small 
once a satisfactory plant is established. 

When buying the gas in small quantities, most manu- 
facturers require a deposit covering the value of the cylin- 
der, this deposit being returnable upon the receipt of the 
empty cylinder. The deposit required on the 100-gallon 
cylinder is about $5.00 for each cylinder. Cylinders con- 
taining N 2 are usually painted black or blue while those 
containing oxygen are red or bronzed. 

General Considerations. — With nitrous oxide alone one 
can obtain only an incomplete anaesthesia. The length of 
the administration is definitely limited by the physiological 
reaction of the organism to the drug. This reaction is 
as follows : 

When N 2 is breathed to the total exclusion of air the 
patient experiences a sense of exhilaration. The extremi- 
ties tingle and quickly grow numb. A necessity to breathe 



NITROUS OXIDE 207 

or " besoin de respire " makes itself felt and the respira- 
tion automatically becomes full and deep. Consciousness 
is completely lost in less than half a minute in the ordinary 
case. This may be preceded, accompanied or immediately 
followed by flashes of light or loud sounds. Many patients 
experience no sensations whatever. If the administration 
is continued, air and oxygen being excluded, the patient 
rapidly becomes pallid, then blue or gray. The muscles 
of the face and limbs are thrown into convulsions known 
as jactitation, the respiratory movements become irregu- 
lar and finally cease. 

Immediately upon the admission of air the patient 
resumes normal respirations and color. Consciousness 
returns in less than two minutes. 

Nitrous oxide has been administered hundreds of thou- 
sands of times to a degree of partial asphyxia. The pro- 
cedure is indeed so common among dentists and occasion- 
ally among house officers that many men have come to look 
upon N 2 anaesthesia as implying lividity. It is true that 
in order to obtain the longest " available anaesthesia," it is 
necessary to push gas to an asphyxial degree where oxygen 
is not employed. Such a procedure is bad taste to say 
the least, and should not be practised. One should manage 
to get along with a shorter anaesthesia, reapply the mask or 
add oxygen to the mixture. 

Apparatus. — In order to obtain satisfactory results 
an absolutely air tight apparatus must be employed. The 
author's apparatus, Fig. 72, offers a type which is satis- 
factory. 

Administration. — When N 2 is Used to Induce 
Ether Anaesthesia. — This administration is a routine pro- 
cedure in most large hospitals. By rapidly and safely 



208 ANESTHESIA 

destroying consciousness the patient is spared a most dis- 
tressing experience. When we use N 2 for induction we 
accomplish three results: 

1,2. We destroy consciousness and render the mucous 
membranes less sensitive to ether vapor. 

3. We induce deep breathing which permits us to 
rapidly reach the desired concentration of ether in the 
patient's blood. 

Since hearing is one of the last senses to disappear it is 
unwise to ask the patient whether or not he is asleep. A 
semi-conscious response may result. 

The bag of the inhaler, usually of two gallon capacity, 
is filled with N 2 0. The apparatus is applied and the pa- 
tient is instructed to breathe out naturally through the 
mouth. The first three breaths may be spilled into the air 
by the expiratory valve, or rebreathing may be practised 
from the start. Where the latter method is employed re- 
sults are entirely satisfactory and a single bag of gas is 
usually sufficient. As soon as the respirations have become 
full and deep, and evidently involuntary, ether is very cau- 
tiously added. If the rhythm of the breathing is affected 
it should be withheld for a few moments and then a second 
attempt made. If no hesitation occurs the ether may be 
rapidly increased. As soon as the patient has received a 
few breaths of ether, air is added a breath at a time. By 
this technic we have no blue or even dusky patients at our 
gas induction. 

When Nitrous Oocide is Used Alone. — This type of 
administration is the method usually employed in dental 
work. When a tooth is to be extracted a mouth prop of 
cork or other material, made especially for the purpose, 
must be placed in position before the administration i 



NITROUS OXIDE 



209 



begun. The patient furthermore is ordinarily in a sitting 
position. The head must not be extended but should be 
on a straight line with the body. The administration is 
carried out precisely as in the case of N 2 induction for 
ether except that (oxygen not being used) we carry on 
the administration until slight jactitation of the arms or 
legs takes place. 

If anaesthesia be then discontinued, a period of available 
anaesthesia amounting to about fifty seconds will result. 

B 




Fig. 99. — The author's cylinder holder. A, brass plate clamp for three one-hundred gallon 
cylinders; B, pin screwing into plate and fitting in socket of table clamp; C, table clamp; D, 
showing by dotted line the buried channel into which the gas of each cylinder empties, all 
leaving for face piece (not here shown) by a single rubber tubing. 

During this period any painful procedure may be carried 
out, such as the extraction of teeth, opening of abscesses, 
etc. When a longer anaesthesia is desired with this method 
the face piece may be reapplied before complete conscious- 
ness returns. If the operation be elsewhere than in the 
mouth one breath of air should be administered after every 
four or five breaths of rebreathed N 2 0. This will give a 
longer period of available anaesthesia, but does not result 
in anything like the smooth anaesthesia offered by the addi- 
tion of oxygen gas to the mixture. 

The author's clamp and cylinder holder consist of 



210 



ANAESTHESIA 



two parts; the cylinder holder and a clamp for use when 
horizontal support may be had i.e., table, etc. 

The cylinder holder consists of two parts; a nickle- 
plated brass plate about two inches by ten inches and a 
threaded steel pin, which may be screwed into the plate 
and removed at will. The plate is drilled so as to receive 
three cylinders. Each hole has a nipple which receives the 




Fig. 100. — The author's cylinder holder clamped to the edge of a table. 

cylinder and a thumb screw which holds the cylinder in 
place. This arrangement gives us the equivalent of three 
yolks sufficiently separated and rigidly united. 

The nipple which receives each cylinder is pierced by a 

hole which opens into a common tunnel made in the plate. 

The exit from this tunnel is from a single vent, to which 

the rubber tubing leading to the face piece is attached. 

(Fig. 99.) 



NITROUS OXIDE 211 

The plate, therefore, is the essential part of the appara- 
tus and may be used alone. When the plate is used with- 
out the clamp (Fig. 101) , three cylinders are fitted into the 
yolks and, thus united, are placed on their sides and used 




Fig. 101. — Cylinders lying on a chair supported by the author's holder. Covered by a blanket 

these may be sat upon. 

in this position. They may be placed on the anaesthetist's 
chair (Fig. 101), and when covered by a blanket form a 
comfortable seat. 

The clamp consists of two flat plates of steel, drilled 



212 



ANAESTHESIA 



with three holes each. Two of these holes receive bolts with 
their nuts, the third receives the pin which is screwed into 
the plate holding the cylinders. This clamp fits over the 
corner of a table. The weight of the cylinders does not in- 
jure the table if the clamp is evenly applied. Tables with 




Fig. 102. — Cylinder clamp fastened to a window-sill. 

glass tops are not affected, as the clamp covers a compara- 
tively broad area. The author has used this clamp on the 
lightest weight, portable operating table (Fig. 100). 

When the patient is to be moved from the stretcher to 
the operating table, the clamp is first fixed to the operating- 
table. The anaesthetic is then started, either in the anaesthe- 



NITROUS OXIDE 213 

tizing room or in the patient's bed, with the cylinders on 
their sides on a table or on a chair. When the operating 
room is reached, the pin of the cylinder holder is conven- 
iently dropped into the holes of the horizontal plate. This 
transfer is done easily and quietly. Thus supported the 
cylinders are completely out of the way. They do not 
clutter up the floor space; are within easy reach of the 
anaesthetist and move with the movements of the operating 
table. 

The custom of using nothing but a yolk, the cylinder 
standing on the floor, is not only dangerous because of the 
liability of the cylinders falling, but is wasteful of gas 
because the valves are often incompletely shut off. 



CHAPTER VIII 
NITROUS OXIDE OXYGEN ANAESTHESIA 

This mixture was first employed by Dr. E. Andrews 
of Chicago in 1868. 

The containers for nitrous oxide are described on page 
201. Oxygen is put out in cylinders containing 10 to 100 
gallons. This gas may be compressed to the necessary 
small bulk without being liquified. Consequently there is 
little or no trouble with the valves of the oxygen tanks. 
These containers are usually painted red or bronzed to 
prevent the possibility of confusing them with N 2 
cylinders, which are blue or black. 

Both N 2 and oxygen tanks should be held rigidly by 
some sort of clamp or stand, in order that the administra- 
tor may manipulate the valves with one hand. The most 
simple clamp for this purpose is that shown on page 209. 
This clamp has proven of the greatest convenience to the 
author. 

Two one-hundred gallon N 2 and one O cylinder may 
be carried loose in any handbag or dress suit case. At least 
two cylinders of nitrous oxide and one cylinder of oxygen 
should always be on hand. A simple and inexpensive 
stand and clamp for hospital use is shown in Fig. 103. 
This may be easily made by the hospital carpenter. 

GENERAL CONSIDERATIONS 

Perhaps no other type of anaesthesia at the present day 
has received as much attention as has the combination of 
gases popularly spoken of as gas oxygen. 

214 



NITROUS OXIDE OXYGEN ANESTHESIA 215 




Fig. 103. — A simple wooden stand for three cylinders, suitable for hospital use. 

In order to produce complete anaesthetic effects, N 2 
must be delivered in a concentration of about 90 per cent. 
(The limits being 75 to 95 per cent.) If the additional 



216 ANAESTHESIA 

10 per cent, be replaced by air the patient will suffer from 
oxygen starvation (only 1/5 of air being oxygen). If, 
however, the additional 10 per cent, be supplied by pure 
oxygen no such asphyxial result will follow. This condi- 
tion holds in practice and explains the great difference 
seen in N 2 anaesthesia with air, and with oxygen. The 
difficulty then which confronts us in gas oxygen anaesthe- 
sia is the necessity of giving N 2 of sufficient concentra- 
tion to produce anaesthesia, and at the same time supply 
adequate oxygenation. 

The permissible variations take place within narrow 
limits. The anaesthesia is induced quickly and recovery 
takes place with astonishing rapidity. 

The exceedingly evanescent effects of the anaesthetic 
make it by far the most difficult to administer. The anaes- 
thetist must not only be constantly alert to the ordinary 
signs of anaesthesia, but he must have learned to distinguish 
shades of lightness and depth, which are of little con- 
sequence in anaesthesia by other agents, i.e., ether, chloro- 
form, etc. In the administration of gas oxygen the 
personal equation is without doubt the most important 
element. 

Anaesthesia by nitrous oxide and oxygen is character- 
ized by muscular rigidity of varying intensity. This 
rigidity is sometimes present in an apparently complete 
and otherwise entirely satisfactory anaesthesia. 

Some patients become very easily controlled, others re- 
main rigid no matter how much the anaesthetic is pushed. 
In this connection one should always remember that relaxa- 
tion will never occur in the presence of cyanosis. If the 
desired result cannot be obtained without the presence of 
asphyxia then ether should be employed. 



NITROUS OXIDE OXYGEN ANAESTHESIA 217 

When nitrous oxide and oxygen is the anaesthetic em- 
ployed the administrator must have the co-operation of 
the surgeon. The surgeon must unbend and the anaesthe- 
tist must rise to the occasion. Gas oxygen anaesthesia 
given by the sub- junior for the chief is very likely to 
be a failure. 

With gas oxygen anaesthesia, more than with any other 
agent, we wish to go on record as insisting that the patient 
be the criterion of the mixture delivered. An anaesthetist, 
who will not give additional oxygen because his apparatus 
indicates a certain theoretical percentage, even though 
the patient be dying of asphyxia, certainly has no business 
to use this method. The author has seen a patient posi- 
tively gray, crying out for oxygen by every possible sign, 
ignored by the anaesthetist, who was sure that all was safe 
because his apparatus showed such and such a percentage 
mixture in process of delivery. If preconceived and pre- 
arranged mixtures do not fit the needs of the patient, these 
must be thrown to the winds and suitable percentages 
employed. * 

The administration of gas and oxygen is gradually 
beginning to find its place. It has thrown off many of its 
early excrescences, such as positive pressure, heated vapors, 
and the like. Numberless apparatus of beautiful design 
and workmanship have died of complexity. Unskilful 
enthusiasts have fortunately lost interest, and are no 
longer forcing the method where it is contraindicated. 
Unfortunately, however, their blunders live on in the minds 
of the surgeons whom they chanced to assist. These ex- 
periences naturally give rise to prejudice against a method 
which is invaluable in its place. The administration of gas 
oxygen anaesthesia is intimately bound up with the present 



218 ANAESTHESIA 

day theories regarding the physiology of C0 2 gas. Since 
this consideration is deserving of more space than can be 
devoted in this section, the reader is referred to the chapter 
on " Carbon Dioxide and Rebreathing," page 296. 

As the symptoms and signs of gas oxygen anaesthe- 
sia change with great rapidity, we must make use of an 
apparatus which will be sufficiently elastic to meet these 
changes of state as they appear. We must be able to 
produce N 2 effects or oxygen effects without delay. 
This result may be obtained by introducing both the gas and 
the oxygen proximal to the rebreathing bag, not at the 
bottom or distal end of the bag as is the usual custom. 
This principle may be applied to any apparatus. Fig. 72 
shows its application in the apparatus used by the author. 
If this method be employed, should the patient show signs 
of ' coming out,' he can be given pure nitrous oxide at 
once. It is not necessary to wait for the contents of the 
rebreathing bag to discharge itself before the effects of 
the N 2 are felt. The same condition applies to the use 
of oxygen, immediate effects being secured upon turning 
on the gas. 

The preliminary use of morphine and atropine is abso- 
lutely necessary for smooth gas oxygen anaesthesia. 

The Signs of Nitrous Oxide Oxygen Anaesthesia 

Color. — The most important sign which we have in 
gas oxygen anaesthesia is the color. As with ether, duski- 
ness is more liable to occur in the full-blooded, muscular 
individual. With ether, however, duskiness or cyanosis 
is usually directly dependent upon obstruction to the res- 
piration, while with gas oxygen the condition frequently 



NITROUS OXIDE OXYGEN ANAESTHESIA 219 

depends upon the mixture of the gases offered to the 
patient. As has been pointed out under general considera- 
tions, complete anaesthesia and a normal color are obtained 
only when oxygen is employed. Those who are unfamiliar 
with gas oxygen anaesthesia, but who have had some ex- 
perience with N 2 alone are very likely to purposely 
avoid a pink color fearing that the patient will " come 
out." A good color is especially desirable where the best 
relaxation is required. By pushing the N 2 to a degree 
of asphyxia, we not only do not overcome the rigidity but 
we superimpose the rigidity which accompanies imperfect 
oxygenation. 

For the above reasons gas oxygen anaesthesia per se 
cannot be satisfactorily administered in the dark, i.e., for 
nose and throat and for cystoscopic examinations. To 
employ this method under these conditions is to court fail- 
ure and to risk the life of the patient. 

The difficulty of properly judging the color in negroes 
excludes them from this method unless special indications 
are present. 'Our haemoxometer is valuable here. 

The color of the patient is the only reliable index of 
the amount of oxygen which should be delivered. Any 
apparatus which does not accept the color of the patient 
as the criterion for the increase or the diminution of the 
oxygen supply is pernicious. Where such apparatus is 
employed as will deliver definite mixtures of N 2 and 
oxygen there must be some provision made for the imme- 
diate and copious admission of oxygen, should such treat- 
ment be found necessary. The margin of safety in gas 
oxygen anaesthesia is narrow, much more narrow than 
with ether and we cannot force our methods as we may 
occasionally do with the latter. 



220 ANAESTHESIA 

Respiration. — Next to the color sign the respiration 
is the most important sign of gas oxygen anaesthesia. 
During the early part of induction the respirations are 
very likely to be more rapid and deeper than normal. In 
some athletic patients this may amount to a hypercapnia, 
which will seriously disturb our induction. If the color is 
held under good control by sufficient oxygen, however, the 
breathing soon becomes less rapid and more shallow. A 
soft snore is one of the first signs of good ancesthesia. If 
this continues, and the respirations remain regular and 
somewhat deeper than normal, the preparation of the field 
of operation may be begun. A patient whose respirations 
are shallow and slow is not anaesthetized. Air has prob- 
ably leaked in under the face piece and manipulations 
begun at this time will result in trouble. One has to " feel 
out " each patient and determine the approximate amount 
of oxygen which is required. The reaction of the respira- 
tion to vigorous " scrubbing up " is valuable. If the 
rhythm is not affected the incision may safely be made. 
During the maintenance of the anaesthetic the rhythm 
and the depth of the respirations, in conjunction with the 
color, form our chief guide as to the condition of the 
patient. The most important factor in the control of the 
respiration is the extent to which rebreathing is permitted. 
The stimulating effect of the C0 2 thus obtained is more 
active than where ether is the anaesthetic (see page 803). 

Relaxation. — With gas oxygen anaesthesia there is 
no true relaxation (see page 57). We expect and 
usually find more or less rigidity. The muscle tone is 
prone to persist. The impossibility of obtaining true mus- 
cular relaxation when gas oxygen is the anaesthetic is being 
borne in upon us by repeated failures where these gases 



NITROUS OXIDE OXYGEN ANESTHESIA mi 

used alone are employed for abdominal work. The proper 
understanding of this rigidity by the surgeon and the 
anaesthetist will produce far more satisfactory results. 
The surgeon must realize the conditions under which he 
is obliged to work. The anaesthetist must realize the 
effects which he can produce, know when he has reached 
the limit and not persist in attempting the impossible at 
the expense of the patient and the surgeon. 

If absolute relaxation is not essential, however, for 
the work in hand, gas oxygen anaesthesia gives great 
satisfaction. 

When induction has been completely brought about 
the lid reflex will be sluggish. Slight muscular move- 
ments of the limbs occasionally occur but as a rule the 
patient is absolutely quiet. Masseteric relaxation is never 
complete where the gases are employed without ether. 

The Pulse. — A slow pulse, fifty or less, under gas 
oxygen anaesthesia is a danger sign. Rebreathing should 
be diminished and the general condition of the patient care- 
fully watched. 

The Eye Signs. — When anaesthesia is fully induced 
the globes are fixed, looking forward, downward or upward. 
( This sign is a guarantee that consciousness is lost. ) 

During the stage of maintenance the light reflex is 
active; the pupils are contracted; the conjunctivo palpe- 
bral reflex is active; the corneal reflex is always snappy. 

The Point of View of the Surgeon, Anaesthetist and 
Patient in Regard to Gas Oxygen Anesthesia 

The inconvenience of the surgeon adapting himself to 
an anaesthesia which does not yield complete muscular 
relaxation is certainly a serious objection. A man who has 



222 ANAESTHESIA 

been accustomed for years to the freedom of manipulation 
which ether affords when properly administered often 
finds it not only difficult but impractical to work with this 
anaesthetic. His attitude will be largely governed by his 
estimation of the value of gas oxygen in the recovery and 
convalescence of the patient. 

The Anesthetist. — Gas oxygen anaesthesia is by far 
the most difficult of all anaesthetics to administer. From 
the aspect of mere labor the method is unpopular for those 
who simply give " dope;" but for the man who can catch 
the spirit of the work, for the man who is interested in 
the Art of Anaesthesia the method is fascinating. The 
recovery in a case of gas oxygen anaesthesia properly 
administered is a triumph in itself. 

The Patient. — From the point of view of the patient 
the method is the most satisfactory yet devised. After- 
symptoms are conspicuous by their absence. The patient 
is scarcely ever sick although retching before consciousness 
returns is frequently seen. The disadvantage of a rapid 
return of consciousness is so far outbalanced by the bene- 
fits as to be of little consequence. To see a patient pass 
in two minutes from a stage of deep anaesthesia, in which 
he has been maintained for an hour or more, to complete 
consciousness is the marvel of present-day anaesthesia. 
And by consciousness we mean complete orientation ; a con- 
sciousness which is capable of calmly surveying immediate 
past experiences and which fully understands existing 
conditions. 



CHAPTER IX 
NITROUS OXIDE OXYGEN ETHER ANESTHESIA 

Owing to the ob j ectionable muscular tone and rigidity 
which exist when gas oxygen is given per se, even though 
preceded by morphine and atropine, ether has been added 
to a greater or less degree. 

The addition of small amounts of ether greatly in- 
creases the efficiency of the control. Owing to the deep 
and rapid respirations which obtain in gas oxygen anaes- 
thesia it is quite easy to quickly introduce ether into the 
circulation. For the same reason ether once introduced 
and then stopped may be rapidly expelled by rebreathing 
gas and oxygen. 

When ether is used in sufficient quantity at the proper 
time, we believe that the resulting anaesthesia is the best 
all-round method thus far devised. Where relaxation is 
necessary for the surgeon, we believe that ether should be 
freely used. 

The author's method of choice in all adults where the 
operation does not involve the respiratory tract is as 
follows : 

A preliminary hypodermic of morphine 1/6 and atro- 
pine 1/150 is given half an hour before the time set for 
operation. Anaesthesia is induced with gas alone or with 
gas oxygen. If the operation be intra-abdominal, a com- 
plete ether anaesthesia by the closed method is then ob- 
tained. The best relaxation is thus secured for explora- 
tion. If intestinal work is now to be done (the visceral 
peritoneum being insensitive) the ether is stopped and gas 
oxygen is used. If the gall-bladder be manipulated and 

223 



224 ANESTHESIA 

reflex rigidity ensue, ether may again be resorted to. At 
the beginning of the stage of recovery (see page 74), or 
when the peritoneum is closed, the ether is completely shut 
off and ga,? oxygen alone is used with very little rebreath- 
ing. By the time the operation is concluded (15-20 min- 
utes) so much of the ether has been thrown off that there 
is scarcely any ether on the patient's breath. The return 
of consciousness is somewhat more delayed than with gas 
oxygen per se. The after-symptoms are conspicuous by 
their absence; persistent nausea and vomiting being very 
uncommon. ( This method has frequently been employed 
by W. B. Gatch and others.) 

Such a type of anaesthesia is ideal for the surgeon, more 
satisfactory for the anaesthetist and from the point of view 
of the patient approaches the ideal obtained by the use of 
gas oxygen alone. 

Where ether is freely used it is not so essential to pre- 
cede the administration by morphine and atropine. The 
effects are generally better when this treatment is followed, 
however, as the pain of the wound is minimized after the 
recovery of the patient, who often falls into a light sleep 
shortly after returning to bed. 

By the employment of this method we believe that we 
obtain the best all-round results: rapid induction, com- 
plete relaxation, ready control, minimum after-effects, all 
with the greatest pathological safety to the patient. 

The Administration of Gas Oxygen Ether 
Anaesthesia 
Two methods of administration are recognized : 

1. The method of intermittent flow with rebreathing. 

2. The method of constant flow (a) with rebreathing; 
(b) without rebreathing. 



NITROUS OXIDE OXYGEN ETHER ANAESTHESIA 225 

The Administration of Gas Oxygen Ether Anes- 
thesia by the Method of Intermittent Flow with 
Rebreathing 

This method is the simpler of the two, consumes about 
half the amount of gases but is thought by some to give a 
somewhat more uneven level of maintenance. This method 
is the one introduced by W. Gatch, of Johns Hopkins 
Hospital, Baltimore. It requires the closest attention to 
detail as does, in fact, any method of gas oxygen anaesthesia^ 
The author has en j oyed such success with this method that 
he is reluctant to replace it by others. 
For apparatus used see Fig. 72. 
The administration is conducted as follows : 
The use of a preliminary hypodermic of morphine gr. 
1/4 and atropine gr. 1/150, where not distinctly contraindi- 
cated, administered half an hour before anaesthesia, is 
absolutely essential to the success of nitrous oxide oxygen 
anaesthesia. 

Hyoscine gr. 1/100 and morphine gr. 1/4 one hour 
before anaesthesia are an ideal medication in large muscular 
people. The disadvantages of hyoscine are largely coun- 
teracted by the employment of rebreathing. 

It is difficult to overestimate the value of suggestion. 
A few words of sympathetic reassurance will do much 
towards improving the anaesthesia. 

Experience only will give familiarity with the appara- 
tus and the best results. If the nitrous oxide and oxygen 
cannot be made to work in a particular case, ether and 
oxygen may be given by the closed method. 

Before starting the anaesthesia, take the piece of wire 
gauze supplied (2 inches by 15 inches of the size known as 100 
to the inch) . Make a roll of this and place it under the ether 

15 



226 ANAESTHESIA 

cup. Assemble the apparatus and by a little twist open 
the dome top. This cuts out the gas and ether chamber. 
Fill the bag slowly, by little spurts, with nitrous oxide. 
(Rapid filling causes frozen valves, cold gas and noise.) 
See that the needle valve is closed. Fill the ether cup. 
Place an ether can cork, with a string tied to it, on its 
side between the right front molars. Apply face piece, 
being particularly careful of the coaptation over the bridge 
of the nose and under cheek. Turn the head to the right 
side and instruct the patient to breathe naturally through 
the mouth. He is now getting only air. Push down air 
shut-off, and fasten by twist. The patient is now re- 
breathing nitrous oxide. 

Open the expiratory valve and the patient will begin to 
empty the bag. Allow the bag to empty about two-thirds, 
release the expiratory valve and slowly run in more nitrous 
oxide and a little oxygen. The amount of oxygen can 
only be learned by experience. (20 to 30% by Oxyhgemo- 
globinometer. ) The breathing will become deep and 
full. Presently a snoring will be heard. This is a 
sign of sufficient anaesthesia to start scrubbing up. In 
shallow breathers this may be delayed for some time. If 
the snore is absent after four or five minutes, cautiously 
drop in a little ether. If the respirations continue un- 
changed, there are good evidences that the patient is well 
anaesthetized. The conj unctivo-corneal reflexes are so ac- 
tive that in the early stages particularly they are of little 
assistance. 

It is always well to test out the patient's reaction to 
ether, as later, particularly in abdominal operations, ether 
becomes an absolute necessity for the relaxation of the 
abdominal muscles. 



NITROUS OXIDE OXYGEN ETHER ANESTHESIA 227 

The reaction of the respiration and any slight move- 
ment during the scrubbing up will give one a good idea of 
the depth of the anaesthesia. Just before the incision is 
made, particularly in abdominal cases, increase the per- 
centage of nitrous oxide by half emptying the bag and 
refilling with pure nitrous oxide. At the same time have 
the patient under ether control. That is, have him where 
he will accept ether without spasm. If the respiration is 
not affected by the incision, if there is no slight movement 
of the extremities, and the surgeon does not complain of 
abdominal rigidity, stop the ether and carry the patient 
along on a faint pink color. ( Not more than 20% cyanosis) . 

The respiration must be kept free. The use of the 
ether can cork now becomes apparent. In the case of 
obstruction, the teeth are sufficiently separated to admit of 
the easy introduction of the mouth gag in the upper or 
left side of the mouth. The throat tube may then be 
inserted without difficulty. This will be found of greatest 
assistance where indicated. 

Should necessity arise, particularly in the early stages 
for considerable ether, one need not be alarmed, for this 
ether can be disposed of by stopping its administra- 
tion early, using only gas and oxygen, and frequently 
emptying the bag. During the course of an even anaesthe- 
sia, when adding nitrous oxide and oxygen, it has been 
found more satisfactory not to empty the bag completely, 
but about half the bag at the time, this being repeated 
every two or three minutes. This does not make such a 
radical change in the mixture and never leaves the bag 
without carbon dioxide, the respiratory stimulant. 

Trouble. — If one is in trouble and cannot determine 
just where the patient is, always give him the benefit of the 



228 ANESTHESIA 

doubt, and stop the anaesthetic by opening the air vent. 
The contents of the bag are saved and ready for immediate 
reapplication. A few breaths of fresh air will change the 
picture completely and assure safety. 

Respiration very deep and slow — usually too much 
rebreathing — empty the bag completely and refill. 

Spasm of the respiration — stop ether completely, 
empty bag and give either air or oxygen, with a small per- 
centage of nitrous oxide. 

The mouth tube, if introduced under nitrous oxide and 
oxygen anaesthesia alone, is likely to cause irritation lead- 
ing to respiratory spasm and possibly vomiting. Precede 
introduction by a little ether. 

Shallow breathing under hyoscine — increase carbon 
dioxide by rebreathing. 

Respirations deep and slow, growing shallower and 
remaining slow (5-10) a minute — suspect Cheyne Stokes 
respiration, stop the anaesthetic and seek cause for trouble. 

Rapid respiration, corneal reflex gone — probably too 
much ether. 

Abdominal rigidity in the presence of deep ether — res- 
piration obstructed or faulty position on the table. 

Movement — profound gas anaesthesia, jactitation, or 
anaesthesia incomplete. 

Pulse slower than normal — too much rebreathing, 
danger signal. 

Blue — too large percentage of gas, or respiratory 
obstruction or both, refer to Oxyhaemaglobinometer. 

Bright-red — too much oxygen, valves in oxygen cylin- 
der leaking, not shut off, or air leaking in about the face 
piece. 

Don't expect a bright color in sallow people. 

Do not give gas and oxygen to negroes unless escaping 
blood or mucous membrane can be watched. 



NITROUS OXIDE OXYGEN ETHER ANAESTHESIA 

Sweating : forehead warm — too much rebreathing. 

Sweating: forehead cold — shock. 

Increased hemorrhage of dark blood — respiratory ob- 
struction alone or combined with too much rebreathing 
and nitrous oxide. 

Swallowing — an indication of shallow anaesthesia, im- 
mediately precedes vomiting. Increase anaesthesia by gas 
or ether. 

Vomiting — stop anaesthesia, allow reflexes to return 
and thereby provide against the aspiration of vomitus. 

Immediately following an attack of vomiting the pa- 
tient will return quickly and smoothly to the anaesthetic 
state. 

Retching — increase gas and ether. 

Sphincter dilation and gall-bladder work may show it- 
self reflexly even in the presence of a sufficiently deep 
anaesthesia. 

Vomiting may be purely morphine in origin. 

Vomiting during recovery seems to depend upon the 
use of morphine, the preparation of the patient, the nature 
of the operation, the amount of ether used, and the degree 
to which rebreathing is carried. 

Hysteria — use suggestion, and morphine combined 
with hyoscine. 

Hiccough — rare in nitrous oxide oxygen anaesthesia; 
increase gas and rebreathing. 

Headache during recovery — uneven anaesthesia with 
too much rebreathing. 

Pupil dilated, corneal reflex gone — profound anaes- 
thesia. 

Nystagmus and active corneal-lid reflex — shallow 
anaesthesia. 

Hearing is acute during the early stages of nitrous 
oxide oxygen anaesthesia — be quiet. 



230 



ANAESTHESIA 



Administration of Gas Oxygen Ether Anaesthesia 
by the Method of Constant Flow with Re- 
breathing 

The constant flow of gas with limited rebreathing is 
employed by A. H. Miller of Providence whose apparatus 
(Fig. 104) represents a popular type. 

This apparatus is very ingen- 
ious and simple in the work 
which it is expected to perform. 
The control is somewhat more 
ready and its employment does 
not require so much mechanical 
sense as does the use of the inter- 
mittent flow. This apparatus 
provides a definite flow of ni- 
trous oxide and oxygen each 
measured in litres per minute 
to which may be added a definite 
flow of vaporized ether measured 
in c.c. per minute. 

Two reducing valves, one for 
nitrous oxide, and one for oxy- 
gen, are provided (Fig. 104). 

The McKesson Apparatus, 
(Fig. 105) is a departure 
from the usual continuous flow principle which has been 
commonly employed in gas oxygen devices. In this appa- 
ratus, the breathing of the patient regulates the volume of 
the two gases admitted into the apparatus from the tanks 
and interrupts the flow during the periods of exhalation 
and respiratory pause. The apparent purpose of such a 
procedure is to eliminate adjustments of the flow rate by 




Fig. 104. — Miller apparatus. 
(Courtesy Dr. Miller.) 



NITROUS OXIDE OXYGEN ETHER ANESTHESIA 231 



hand, making the apparatus mechanically perform in a 
more perfect manner, those things which are arduous and 
imperfectly controlled by the anaesthetist. This auto- 
matic action also saves gases by preventing a certain 
amount of waste occur- 
ring in continuous flow 
devices, and by the sound 
of flow during inhalations, 
warns the anaesthetist 
when the patient's res- 
pirations are ineffective. 
The rebreathing de- 
vice on the McKesson 
apparatus is unique. It 
consists of a small bag, 
adjustable in capacity and 
graduated in cubic centi- 
metres, so that the rate 
of ventilation may be 
ascertained by measur- 
i n g the tidal volume 
and multiplying it by 

the rate Of respiration. Fig. 105.— McKesson apparatus. 

Based upon the ventilation as the criterion of rebreathing, 
any amount of rebreathing may be performed as desired 
by setting the bag for the desired volume. 

The Connell Gas and Oxygen Apparatus, (Fig. 107) is 
compact, well made and has given much satisfaction. It re- 
presents the outcome of investigation made by Dr. Karl 
Connell to whom we are indebted for the Ansesthetometer 
and the motor blower apparatus previously described. 




232 



ANAESTHESIA 



The Gwathmey Gas Oxygen Apparatus, (Fig. 106) is 
one of the most satisfactory and popular of all Gas Oxygen 
Machines. It is practical in its construction and stands 
a great deal of routine hospital abuse. 

Administration of Gas Oxygen Anaesthesia by the 
Method of Constant Flow Without Rebreathing 







This method is quite different 
from those methods which employ 
rebreathing. By this method an 
attempt has been made to adminis- 
ter N 2 and O on a basis of vapor 
tension reducing the matter to 
terms of ether by the percentage 
method (see page 64.) Dr. K. 
Connell has arranged the chart 
shown in Fig. 108, in which the 
effect of different percentages of 
N 2 and vapor are shown. Theo- 
retically the method is ideal. Its 
limited employment thus far, how- 
ever, compels us to reserve our 
opinion as to its practicability. In a general way we feel the 
necessity of being very near the patient when we administer 
gas and oxygen. Any method which tends to release us 
from this responsibility is likely to result in sudden disturb- 
ance, either of lightness or depth. 

From a point of view of expense of administration the 
method of intermittent use is the least expensive, and 



V&e« 



Fig. 106. — The Gwathmey gas 
Oxygen apparatus. 



NITROUS OXIDE OXYGEN ETHER ANAESTHESIA 233 

the percentage method with the constant flow the most 

expensive. 

The intermittent flow is exemplified by the Gatch ap- 
paratus. One hundred cases anaes- 
thetized by this method were sum- 
marized as follows: 

Youngest 3; oldest 70; 76% 
females; morphine and atro- 
pine in 63% ; total time of 
administration 103 hours ; 
nitrous oxide used 3,470 gals.; 
oxygen 768 gals. by actual 
weight; 45 of these adminis- 
trations were a complete 
success from every point of 
view; 42 were fairly success- 
ful; 12 were failures and 1 
patient died. This death was re- 
ported in detail in N. Y. State 
Medical Journal. FlG . io7.-conneii gas o xyg en 

Apparatus. 

General Observations Based Upon Ten Years' Ex- 
perience With Xitrous Oxide Oxygen 
as an Anaesthetic 




Method of Administration. — The administration 
of gas oxygen by the method of intermittent flow 
demanded a certain mechanical dexterity on the part of 
the operator, a discriminating judgment in the dosage of 
the gases, combined with a willingness to exert oneself a 
little more than usual. These qualities being by no means 
universally possessed by Anaesthetists, a concerted effort 



234 



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Fig. 109. — Connell nitrous oxide, oxygen, ether flow control. A, nitrous oxide instanta- 
neous gas-flow gauge (piston type) ; B, oxygen gauge (piston type); C, parachute gauge.com 
bined gases; D, ether tank; E, ether dropper; F, gas-control cocks; G, outlet. (Courtesy Dr. 
K Connell, Appleton Co., Johnson's Surgery.) 



NITROUS OXIDE OXYGEN ETHER ANAESTHESIA 235 

was made to simplify the delivery of the gases to the patient, 
thereby bringing this form of anaesthesia within the reach 
of all. 

Various contrivances were devised to yield a constant 
flow of gas oxygen under a definite pressure; these 
gases being mechanically mixed so that any desired per- 
centage was obtainable. 

It was not long before the market was flooded with 
beautifully designed instruments ingenious in their con- 
struction and capable in most cases of achieving the end 
desired. Broadly speaking, these apparatus designed for 
a constant flow of a definite percentage, required reducing 
valves, a heating element (electricity or alcohol) and a 
device for measuring and mixing the gases as they were de- 
livered to the patient. 

The administration of gas oxygen was thereby simpli- 
fied, but this simplicity implied the constant upkeep and 
perfect functioning of a complicated machine. In large 
surgical clinics constant use resulted in a fair degree of 
success. In the operating-room where only an occasional 
gas oxygen was administered, however, the complicated 
apparatus has become merely ornamental and a collector 
of dust. 

On the other hand, the method of intermittent flow re- 
quiring nothing but a simple cylinder holder is practically 
always available and when coupled with the necessary 
qualifications in the person of the operator is usually en- 
tirely satisfactory for all but nasal* administration. 

The use of Adjuvants. — It has always been consid- 
ered desirable to add a few drops of ether, if necessary to 
secure proper muscular relaxation. These minims often 
become drams and occasionally ounces. 



236 ANAESTHESIA 

Morphine and Atropine, Hyocine, Paraldehyde and 
other drugs have always been found necessary to take the 
edge off the reflexes under gas oxygen. Indeed, it is abso- 
lutely essential that full preliminary medication be em- 
ployed if one wishes to secure the best effects of gas oxy- 
gen. There is a remarkable difference in reaction between 
V 6 grain and V* grain of morphine. A dose of Ve grain 
always leaves something to be desired. Where the physi- 
cal condition of the patient does not contro-indicate a full 
dose, 1 / 4 grain is always to be given. Hyocine in doses of 
1/100 of a grain is a splendid preliminary. 

The use of local anaesthesia as an adjuvant to gas oxy- 
gen is a matter of personal equation. If well done, it is 
ideal ; if poorly done, in haste, it is much worse than noth- 
ing at all. The best possible example of the use of adjuv- 
ants is seen in Dr. Criles' Anoci Association. Employing 
this technique, the surgeon makes a "virtue of necessity." 
For, upon overreaching the limit of an area blocked by the 
novocaine and obtaining a reflex response to pain and 
trauma, he obscures the obvious fact that the patient is 
not anaesthetized by stating that he is glad to see this reflex 
so that he may know the limits of his area of local anaesthe- 
sia. Gas oxygen in this technique serves merely to com- 
plete the unconsciousness largely attained by the full pre- 
liminary medication. 

What then are the reasons for the rapid and wide- 
spread adoption of gas oxygen 9 We would enumerate 
these as follows: 

1. The speedy and usually pleasant loss of conscious- 
ness. 

2. The satisfaction experienced by the Surgeon in 
having the patient fully awake and conscious on the oper- 
ating-table. 

3. The reduced after-sickness. 



NITROUS OXIDE OXYGEN ETHER ANAESTHESIA 237 

4. The absence of abnormal blood and urine chemistry. 

5. The impression created on the patient by the method. 

6. The direct effect of commercial interests. 

Muscular Relaxation Under Gas and Oxygen. — 
The great and real difficulty in gas and oxygen is the 
absence of true muscular relaxation. Gas oxygen enthus- 
iasts decry the need of complete relaxation. They assert 
that the operator should so make his manipulations as to 
avoid spasm and trauma. The result is that the occasional 
operator, the man who needs complete relaxation more 
than anyone else, listens to this plea, narrows his field of 
operation and limits himself to the simplest type of opera- 
tive interference. He cannot do gall bladder and stomach 
surgery because he never has a chance to expose these 
regions and to keep them quietly exposed. Not infre- 
quently, a patient appears to be completely relaxed under 
gas and oxygen. The writer feels, however, that the relax- 
ation seen under these conditions is not a true muscular 
relaxation, but merely an absence of rigidity. Muscle 
tone still obtains. 

Hemorrhage. — During the days that the writer em- 
ployed gas and oxygen anaesthesia for every case without 
selection, he frequently found the objection raised that the 
bleeding was increased. He recalls one man in particular 
who would never yield on this point. The objection was 
put down at the time as an unwarranted prejudice and 
discounted as such. That this objection was correct, how- 
ever, has often been emphasized by the fact that increased 
oozing is now one of the accepted phenomena of gas 
oxygen anaesthesia. Enthusiasm for gas oxygen has been 
carried to such a point that we have been advised to disre- 
gard the color sign, to ignore cyanosis. A well-known 
gas oxygen Anaesthetist employs a preliminary saturation 



238 ANAESTHESIA 

test with nitrous oxide in very ill patients to determine 
whether or not they are capable of living through the con- 
templated gas oxygen anaesthesia and operation. 

It is contended by some that a certain percentage of 
patients do not receive the full effects of nitrous oxide 
unless saturation is complete. Such a patient is therefore 
to be given pure NO until livid, with pupils dilated and 
respiration all but suppressed. Oxygen is then to be 
insufflated whereupon complete relaxation is assured. We 
strongly suspect that relaxation so obtained is the result 
of complete exhaustion instead of the benevolent effect of 
NO as a relaxant and because of this we do not hesitate 
to condemn such a procedure. If relaxation can only be 
had with gas and oxygen by such treatment we much pre- 
fer to recommend and to use ether. 

Location of Operative Field. — In choosing gas 
oxygen as an anaesthetic, one of the most important things 
to consider is the anatomical location of the field of opera- 
tion. 

Is the operation to be performed on the head or neck, 
thorax, abdomen, pelvis, kidney region, perineum or upon 
one of the extremities? 

Gas and oxygen has often been used for mastoids, 
goitres, glands of the neck, trephining and occasionally 
for plastic operations on the face. In these regions, how- 
ever, it is practically impossible to preserve complete 
asepsis and to avoid increased hemorrhage. It is difficult 
to maintain the mechanical control of the inhaler and the 
patient's air-way. Asepsis, control or both are usually 
sacrificed. Where this sacrifice is made without an urgent 
reason, the choice of gas and oxygen is a bad one. To 
give gas oxygen for head and neck operations for mere 



NITROUS OXIDE! OXYGEN ETHER ANESTHESIA 239 

sentimental or aesthetic reasons is entirely unjustifiable. 

Gas and oxygen anaesthesia is well suited for opera- 
tions upon the thorax. Here relaxation is not essential. 
Asepsis is not interfered with and the control is good. It 
is particularly to be recommended in acute pneumonic 
processes and in advanced tuberculosis. The work of 
Rovsing and Mikuelicz (Mikuelicz Report of 1898 — 
Rovsing P. 85) on post operative pneumonia, as well as 
that of Whipple has cast considerable doubt upon the 
existence of so-called ether pneumonia, so that in our use 
of gas and oxygen for acute pulmonary processes, our 
object is chiefly to retain or to return the reflexes promptly. 
To control and direct the patient's cough is especially 
desirable in operations for empyemia. 

In operations of the upper abdomen, gas oxygen is 
decidedly unsatisfactory. In fact, ft is here that it has 
so frequently met its Waterloo. Complete anaesthesia 
and complete relaxation must obtain in this region if the 
surgeon is to do his best work. In the lower abdomen, 
on the other hand, it is often quite possible to hold a patient 
for an appendectomy done through a small incision. 

Intestinal work, involving the visceral peritoneum is 
practically painless and the patient will slumber through 
this period quietly enough. Examination of the pelvis or 
upper abdomen usually results in spasm or rigidity which 
passes off when the irritation is removed. The patient is 
then quiet again until the peritoneum is caught hold of for 
closure when rigidity once more occurs. Gastrostomies 
and colostomies may be done under gas and oxygen if 
the surgeon is a man who can work in the presence of a 
little rigidity. 

Operations performed in the pelvis of multipara may 



240 ANAESTHESIA 

be done with a fair degree of success, but failure will attend 
an attempt to operate upon the pelvic organs of a vigorous, 
muscular female or male subject. 

Nephrotomies, nephropexies, nephrectomies and opera- 
tions for nephrolithiasis can be handled quite well under 
gas and oxygen provided the anaesthetic is started with 
the patient lying on his side and suitably restrained. 

Gas oxygen is indicated in prostalectomies, lithro- 
pexies, urethrotomies and other operations upon the genito- 
urinary tract of patients having a decreased elimination. 
Cases of circumcision are not easy to control. 

Curretages in multipara, amputation of the cervix or 
vaginal hysterectomy may be done in suitable cases. Per- 
rineorraphies, however, are more difficult. Many hysteri- 
cal nullipara will fail to be subdued by gas and oxygen 
and will require a straight forward ether anaesthesia. 

It is practically impossible to anaesthetize patients with 
gas and oxygen who are to be operated upon for hemor- 
rhoids, ischio rectal abscess or fistula, if this procedure is 
to be preceded by complete anal dilation. 

Infections of the hands and feet should be relieved 
under gas and oxygen, but it will be found that patients 
who are suffering operation upon the soles of the feet, 
such as for a broken needle, etc., are very difficult to control. 

Where dislocations are to be reduced and fractures 
corrected and immobilized, ether is usually required and 
should be freely used. 

Gas and Oxygen in the Specialties. — This form of 
anaesthesia is not practical in eye work. 

Surgery of the ear, such as mastoid operations, sinus 
explorations and operations upon the semi-circular canal 
have been done under gas and oxygen with considerable 



NITROUS OXIDE OXYGEN ETHER ANAESTHESIA 241 

difficulty, imperfect asepsis, hemorrhage and the risk which 
comes from improper illumination. 

Brain surgery is so dependent upon variations in blood 
pressure and oozing, that gas oxygen should not be used. 

Gas oxygen is the routine in some clinics where goitre 
surgery is done. Unless the method of Anoci Association 
is employed, this is attended with great difficulty, increased 
hemorrhage and breaches of asepsis. 

Gas oxygen is contra-indicated in abdominal surgery. 

Genito urinary surgery is the best field for gas 
and oxygen. 

Gas oxygen is useful in selected gynecological cases 
and is valuable as an analgesic in obstetrics. 

Orthopedic surgery which requires a relaxation cannot 
be satisfactorily accomplished under gas and oxygen. 

The dental specialty, one of the first to make use of 
gas oxygen, will probably continue to employ this anaes- 
thetic for all short and uncomplicated operations. 

Danger. — One of the chief arguments in favor of the 
use of gas oxygen was safety. The mortality was placed 
at about one in 100,000 anaesthesias. That this view is 
entirely fallacious may be seen in the collected reports of 
more than 91 gas oxygen deaths published by Dr. J. F. 
Baldwin (Medical Record, July 29, 1916). It is fair 
to conclude that even a greater number of unreported 
deaths have occurred from this form of anaesthesia. The 
most disquieting element in the entire situation is the ex- 
treme suddenness with which these deaths occur. There 
are practically* no characteristic premonitory signs. The 
heart suddenly ceases to beat and all efforts at resuscitation 
fail. The cause of death is not understood. 

The author feels that gas and oxygen should be used 



242 ANAESTHESIA 

with the greatest respect and never pushed in the face of 
untoward symptoms. 

Indications for Gas and Oxygen 

1. Acute pulmonary diseases in patients over eight 
years of age. 

2. Glyesemia with acetone and diacetic acid. 

3. In acute nephritis or where there is a red test of 
less than 20% the first hour. 

( Sulpho-phenoptalein normal 40-60 1st hour) 
( Sulpho-phenoptalein normal 20-30 2nd hour) 

4. Short operations where muscular relaxation is a 
secondary consideration. 

5. As an analgesic in obstetrics. 

Contra-Indications 

Children under 8-10. 

Upper abdominal or head and neck surgery. 

Wherever muscular relaxation is essential. 

Where morphine cannot be tolerated or has been omit- 
ted. 

In heart disease. 

Where the surgeon cannot brook slight movement. 

Smokers — especially women. 
Reasons for Gradual Discard of Gas and Oxygen as 

a Routine Anaesthetic 

1. Danger. 

2. Irregularity of action. 

3. Impossibility of obtaining true relaxation. 

4. Failure to abolish and hold deep reflexes. 

5. Immunity of certain individuals to its effects. 



NITROUS OXIDE OXYGEN ETHER ANESTHESIA 243 

6. Difficulty of managing intermittent flow and me- 
chanical troubles because of complexity of constant flow. 

7. Employment of Lay Anaesthetists who are incapable 
of passing the theory of their work to others and who are 
incapable of selecting and rejecting cases. 

8. The necessity of adjuvants. 

9. The inability of constant flow methods to pass from 
gas and oxygen to straight ether and back again without 
disturbing the field of operation. 

10. The failure to select cases carefully. 

11. Prohibitive expense. 

The Via Media 

Gas and oxygen for induction. 
Gas and oxygen for recovery in long cases. 
The free use of ether in all gas and oxygen cases 
wherever the patient proves resistant. 

Conclusion 

In the light of the foregoing, it may be assumed that 
gas oxygen anaesthesia has not given satisfaction as a 
routine anaesthetic. In the localities where it has been 
used as a routine anaesthetic, it has passed its peak and has 
in many instances actually been thrown into discard. It 
has a very definite and valuable place, however, in selected 
cases of renal insufficiency, glycaemia, and acute pulmonary 
lesions. Elsewhere it will find a useful sphere as an adju- 
vant to ether during the stages of induction, maintenance 
or recovery. Gas oxygen, because of the difficulty of its 
administration, the incomplete anaesthesia produced and 



244 ANAESTHESIA 

the real danger incidental to its use has given way to the 
safest of all anaesthetics, ether. 

A short time ago, believing that we had found in gas 
oxygen anaesthesia, the safest, most agreeable and effec- 
tive anaesthetic, we grudgingly tolerated ether. To-day, 
realizing the danger, the difficulty of administration and 
the unreliability of gas oxygen, we hesitate to use it alone 
except in selected cases and as an adjuvant to ether. 

ANESTHESIA BY ANOCI ASSOCIATION OR THE COM- 
BINED USE OF LOCAL ANESTHESIA AND GAS 

OXYGEN ETHER ANESTHESIA 
A visitor at a clinic where complete anoci association 
is used cannot fail to catch the remarkable spirit of co- 
operation which pervades the operating personnel. All 
things are made to bend to the welfare of the patient. 
Suggestive therapeutics so valuable as a preliminary treat- 
ment to the anaesthetic are here employed to the fullest 
extent. 

The harmonious blending of suggestion and prelim- 
inary medication before the induction of the anaesthetic; 
gentleness in voice and touch combined with an absolutely 
essential and skilful local anaesthesia of the skin during 
the stage of induction ; the continued use of complete nerve 
blocking and care in the manipulation of the tissues during 
the stage of maintenance, work together for a stage of 
recovery which is ideal. It is the remarkable ensemble 
which produces the result seen with so much pleasure. 

There is nothing very unusual about the administra- 
tion of the gas oxygen per se. It is but complementary 
to more important elements. Briefly such an administra- 
tion may be described as a skilful and complete local 
anaesthesia, well fortified by preliminary medication, upon 



NITROUS OXIDE OXYGEN ETHER ANAESTHESIA 245 

which is superimposed gas oocygen anaesthesia, the essen- 
tial purpose of which is to destroy consciousness. 

Place the gas oxygen anaesthesia first, making the local 
anaesthesia and preliminary medication of secondary im- 
portance and the result is certain failure. 

The nitrous oxide and oxygen (we can scarcely say 
the anaesthetic) is often administered by nurses especially 
trained to this particular type of work. Since the anaes- 
thesia does not proceed to relaxation and consequent res- 
piratory obstruction by the falling back of the tongue, 
little difficulty is experienced in the anaesthetization. The 
chief requirement being to control the color. This is easily 
accomplished by simple and convenient valves in the 
machine used. 

An hour before operation the patient receives mor- 
phine grs. Yd and scopolamine grs. 1/200. If he or she 
be an epileptic the dose of morphine is increased to J4 g rs «> 
the amount of scopolamine remaining unchanged. 

Cases of exophthalmic goitre are anaesthetized in their 
beds and carefully transported to the operating room. All 
other cases are anaesthetized on the operating table in the 
operating room. Before anaesthesia is commenced the an- 
aesthetist speaks a few words to the patient in order to 
quell any anxiety which may be present. Most of the 
cases, however, are well under the influence of their pre- 
liminary medication by this time. Nitrous oxide is then 
made to flow through the face piece and down over the 
face of the patient before the mask is actually applied. 
Cotton is placed over the bridge of the nose, and on the 
cheeks corresponding to the point of contact of the mask 
when applied. A little cotton is also placed about the 
respiratory valve to protect the anaesthetist from the ex- 



246 ANAESTHESIA 

pirations of the patient. An ordinary hand towel is placed 
under the nape of the neck, the ends lying free. The time 
of induction varies from ten to fifteen minutes. The 
period of excitement is seldom seen. Before consciousness 
is lost no restraint is applied, but four attendants, an assis- 
tant anaesthetist, an orderly and two nurses stand by until 
anaesthesia is well under way. When consciousness is lost 
the arms are fastened to the table by wristlets and a strap 
is thrown over the knees. These restraining measures are 
most valuable in case of lightness during maintenance. 
The free ends of the towel lying under the neck are now 
brought forward together over the face piece and clamped 
in such a way as to include the latter and hold it firmly 
against the patient. Cotton is stuffed into the space 
between the face and the towel. By this arrangement 
both hands of the anaesthetist are free. (While such a 
fixation of the face piece would be unwise with ordinary 
ether anaesthesia, because of the pharyngeal relaxation 
obtaining, in this very light form of maintenance, the re- 
tained tonicity of the pharyngeal structures prevents the 
obstruction which would otherwise occur.) If the opera- 
tion is to be on the neck, a covering, half sheet, half gauze, 
is fastened to the patient's chin, the gauze portion being 
thrown over the head of the anaesthetist. Such a cover- 
ing is welcomed by the anaesthetist since it permits of much 
needed ventilation. 

The respiration being tranquil and the color good, the 
skin to be incised is carefully and completely infiltrated 
with a solution of novocaine 1/400. This infiltration, or 
nerve blocking is conscientiously done with every tissue en- 
countered, particular care being exercised to inject the 
peritoneum and the pedicels of the pelvic organs, gall- 



NITROUS OXIDE OXYGEN ETHER ANAESTHESIA Ul 

bladder, etc. A failure to completely block the field of 
operation shows itself in changes in the patient's respira- 
tion, moaning, or slight movements, followed by rigidity. 
Retractors are seldom employed and the utmost gentleness 
is exercised in handling the tissues. 

The administration of the gas and oxygen is of second- 
ary importance ; we find that the chief guide to be followed 
is the color. The patient is the index as to the mixture 
which he receives: he is not forced to accept a theoretical 
mixture. The nitrous oxide and oxygen are usually made 
to flow continuously, partial rebreathing only being per- 
mitted. The limitation of the rebreathing causes the res- 
pirations to be much more shallow than when rebreathing 
is freely employed. When a constant flow is used N 2 is 
delivered at a rate of about one hundred gallons an hour, 
the oxygen varying from five to twenty-five an hour. 

The anaesthetist is constantly attended and assisted by 
a pupil nurse who is well instructed as to her duties. 

There being no confusion in the status of the anaes- 
thetist, as is frequently the case when the junior interne 
occupies this position, the anaesthesia proceeds without an- 
noying instructions from the senior house officers. The 
surgeon, appreciating the fact that the anaesthesia is pri- 
marily a local and secondarily a general anaesthesia, inter- 
prets undesirable rigidity as due to incomplete nerve block 
rather than to the faulty administration of the gas and oxy- 
gen. In cases of exophthalmic goitre the administration of 
the gas and oxygen is continued until the patient has been 
returned to bed and is propped up with pillows. Abun- 
dant assistance is furnished for the transportation. (As 
many as five persons assist in the transportation of goitre 
cases from the place of operation to the room. ) 



248 ANAESTHESIA 

The addition of ether in the early periods of induction 
simplifies the administration to a considerable degree. 
Ether in small quantities is not infrequently used in this 
fashion. Since it is seldom employed during recovery, 
however, it is soon rinsed out by the pure gas oxygen anaes- 
thesia which follows and no ether effects are apparent. The 
free use of ether would complicate rather than assist the 
anaesthesia, for undesirable relaxation of the tongue and 
pharyngeal structures would follow, possibly requiring the 
removal of the face piece for relief. 

The recovery from the anaesthesia is rapid and com- 
plete. Most patients retch once or twice before conscious- 
ness returns. 



B. LOCAL ANESTHESIA 

Local anaesthesia is that type of anaesthesia which in- 
volves only the peripheral nervous system. It may be 
brought about by: 

(a) Freezing. 

(b) Pressure on the nerve trunks or by pressure pro- 
ducing ischaemia of the part. 

(c) By regional intravenous injections of novocaine. 

(d) By the injection of novocaine or some other drug 
into the skin or deeper tissues. 

CHAPTER X 

UNUSUAL METHODS 
I. LOCAL ANESTHESIA BY FREEZING 

The effect of extreme cold applied locally is to produce 
a loss of sensation of the part. This is a very common 
experience following exposure to very low temperatures. 
One's ears, for example, when first exposed to zero weather 
at first tingle, then become painful. As the effect of the 
cold increases, the pain disappears and the sensation is 
lost. The parts are then more or less anaesthetic. They 
can be rubbed or pinched or cut without pain. As thawing 
is gradually accomplished, the pain returns with greatly 
increased severity. Even after complete recovery there 
may be occasional intervals of transient pain familiarly 
known as chilblains. 

Freezing may be artificially brought about by the use 
of the ethyl chloride spray. The rate of evaporation of 
this liquid is so rapid that the surface temperature is 
brought below the freezing point and becomes actually 

249 



250 ANAESTHESIA 

frozen. The freezing process appears to act as a termi- 
nal anaesthetic and is complete in a few seconds. The best 
results are obtained by holding the nozzle of the spray 
about ten inches from the skin and by blowing gently upon 
the surface to assist the evaporation. Freezing is indi- 
cated by the blanching of the part exposed to the action 
of the spray. When cut with a knife the tissues will be 
found to be hard and somewhat brittle. The degree of 
anaesthesia produced by this method is variable. It de- 
pends largely upon the degree to which the skin is frozen. 
As is the case with the ordinary freezing, due to exposure, 
the recovery is painful, and if the freezing has been pro- 
tracted extensive sloughing is apt to follow. 

II. LOCAL ANESTHESIA BY PRESSURE 

Pressure on nerve trunks produces a loss of sensation 
in the tissue supplied by the compressed nerve. This con- 
dition often occurs accidently when pressure is allowed to 
act upon a superficial nerve. Muculospiral paralysis, 
occurring when an anaesthetized patient's arm is allowed to 
hang over edge of the table (Fig. 23), produces this effect. 

Local anaesthesia may be brought about by pressure 
interfering with the circulation. Who has not awakened 
after a long sleep and been shocked to find a strange, cold, 
motionless hand in the bed beside him, and who will forget 
the sense of relief when this strange hand proves to be 
his own? 

Artificially these effects have been produced by pres- 
sure on the nerves supplying parts to be operated upon. 
The practice is very ancient in its usage but the pain 
directly occasioned by the pressure is so annoying that the 
method is of little practical value. 



LOCAL ANAESTHESIA 



251 



A certain degree of ansesthesia may be brought about 
artificially by the employment of an Esmarch bandage, 
(Fig. 110) . This consists of a long, rubber band some three 
inches wide and six feet long, which by being tightly wound 
about the limb beginning at the distal end produces a 
bloodless or ischsemic condition. One may profitably bear 




Fig. 110. — Esmarch bandage. 

in mind this fact when a general anaesthetic is being given 
for an amputation of a limb, which has been previously 
rendered ischsemic by the use of an Esmarch bandage. 

III. LOCAL ANESTHESIA BY REGIONAL INTRA- 
VENOUS INJECTIONS OF NOVOCAINE 

This method is applicable to all operations upon the 
extremities. The most important factor in the technic is 
to produce a completely ischsemic condition of the limb. 



252 ANESTHESIA 

Our object in this method is first to empty the veins 
by the proper use of rubber bandages ; secondly to fill these 
emptied veins with a solution of 5 per cent, novocaine. 
By this procedure we bring not only the superficial but 
also the deep structures under the influence of the anaes- 
thetizing solution. 

The cephalic or basilic vein in the arm, or the internal 
saphenous in the leg, should be marked out. 

With the limb raised an Esmarch bandage is tightly 
applied from the fingers or toes to a point above the site 
of the operation. Where this bandage ends, a second, 
broad Esmarch is applied. This is known as the proximal 
bandage (being nearest the body of patient) . 

The first bandage, that which was used to produce 
ischsemia, is slowly unwound; the unwinding naturally 
beginning where it ceased, i.e., next to the proximal band- 
age and not at the fingers or toes. If some part, say the 
middle third of the forearm, is to be operated upon, the 
bandage is unwound to just below this point. A second, 
broad bandage, the distal bandage, being here applied. 
The space included between the two bandages (which 
should be not less than 10 cm. (2]/ 2 inches) or more than 
25 cm. (10 inches) ) is now cut off from the venous circula- 
tion above and below (Fig. 111). 

If the part to be operated upon be the finger or toe, 
the proximal bandage is applied at the middle of the fore- 
arm and no distal bandage is employed (Fig. 112). 

The vein, which we previously marked out, is now 
located and, under local anaesthesia produced by novocaine, 
it is dissected out as near to the proximal bandage as possi- 
ble. A ligature is then tied here. Using this ligature as 
a retractor, the vein is lifted from its bed and a small slit 



LOCAL ANESTHESIA 



253 



made in its lumen by a pair of scissors. A syringe capable 
of holding 60 c.c, capped with an ordinary intravenous 
cannula, is introduced into the vein and tied into place. 
Forty to 50 c.c, of the solution is then slowly injected. 
Anaesthesia of the segment of the arm between the proxi- 
mal and the distal ligature is rapid and complete. The 




SK/N MARKING OF NOW ISCHEMIC VEIN 




Figs. Ill and 112. — Bandage for regional intravenous. 



solution may be quite easily forced against the obstruction 
offered by the valves of the veins The veins at first swol- 
len by the solution, soon collapse indicating the penetra- 
tion of the fluid into the deep tissues. The anaesthesia of 
the part continues until the proximal bandage is removed. 
The reestablishment of the circulation is rapidly followed 
by a return of the sensation. 



254 ANESTHESIA 

The method may prove serviceable for emergency am- 
putations in situations where a general anaesthetic is for 
one or more reasons contraindicated. 

The method appears more thorough and reliable than 
that offered by surface ansesthesia, for the solution injected 
into the vein reaches and anaesthetizes the deepest struc- 
tures at a single injection. 

This method has been used more than 500 times by 
different operators who report success in about 90 per cent, 
of their cases. 



CHAPTER XI 

USUAL METHODS 

LOCAL ANAESTHESIA BY INJECTIONS OF NOVOCAINE 
AND OTHER DRUGS INTO THE SKIN AND DEEPER 
TISSUES 

Local anaesthesia is usually brought about by: (a) 
surface application; (b) by infiltration into the tissues 
(terminal anaesthesia) ; (c) by injections into or around 
nerve trunks (conductive or regional anaesthesia). 

1. The surface or topical application is used for work 
which involves mucous membranes, i.e., nose and throat 
and genito-urinary operations. Solutions of cocaine .5 to 
1 per cent, with adrenalin are the strengths ordinarily 
employed. 

2. Infiltration anaesthesia ( or terminal anaesthesia) aims 
to anaesthetize the terminal end organs by bringing them 
into contact with the solution. This is the method usually 
employed for superficial operations. 

3. Conductive anaesthesia or regional anaesthesia aims 
to destroy or directly block the conductivity of the nerves 
which supply the part to be operated upon. This is per- 
formed by endoneurial injections (direct injections into 
the nerves) or perineurial injections (bathing the nerve 
trunks with the solution) . This method is often combined 
with terminal anaesthesia. 

Infiltration or Terminal Anesthesia 
Water injected under the skin causes a transient anaes- 
thesia. This is painful of accomplishment and unsatis- 
factory. Solutions of the same specific gravity as the 

255 



256 ANAESTHESIA 

tissues will not produce anaesthesia per se; such solutions, 
normal saline for example, must contain an anaesthetic 
drug to be effective. If the injected fluid which we em- 
ploy is rapidly absorbed its effect will be unsatisfactory. 
To limit this rapid absorption adrenalin is habitually 
added to the solution. The solution should also be capa- 
ble of repeated sterilization. 

The Solutions Used. — Cocaine. — Strength com- 
monly used 1 per cent, to 1/10 of 1 per cent. The solu- 
tion may be made up from standard tablets or from 
Bodines' tubes. The latter are composed of cocaine and 
sodium chloride in such proportion that when mixed with 
sterile water a solution ready for immediate use is formed. 

Novocaine. — Strength commonly used .5 per cent. It 
is the most widely used of all drugs for local anaesthesia 
and ten times safer than cocaine. Its solution may be 
repeatedly boiled. "It is not habit forming," it may be con- 
veniently had in tablet form marketed as novocaine supra- 
renin tablets. These tablets are supposed to be sterile but 
it is safer to boil the solution in which they are dissolved. 

Quinine and Urea. — Strength commonly used .5 to 
1 per cent. This solution is said to be absolutely non- 
toxic. The anaesthetic effects which it produces are more 
lasting than those of cocaine or novocaine. Because of 
this prolonged effect it is often used with a view of control- 
ling post-operative pain. Some have claimed that it helps 
to control hemorrhage after operation by causing a deposit 
of fibrin over the exposed vessels; others have contended 
that its employment interfered with the healing of the 
tissues. If one wishes a prolonged action it is well to wait 
fifteen to twenty minutes before incising the tissues 
injected. 



USUAL METHODS 



257 



The Syringe. — The ordinary hypodermic syringe of 
all glass or metal may be used, but, the latest and best in- 
strument is that devised by Doctor Louis Dunn. (Fig. 
113) . Syringes should be boiled in plain water and after 
using dried carefully and a drop of castor oil run in. This 
prevents the sticking of the piston in the all glass syringe 
and the drying out of the packing in the metal syringe. 




Fig. 113. — Dunn automatic outfit for local anaesthesia assembled ready for use. 



Needles. — Steel needles are satisfactory. A variety 
of sizes should be on hand. These should range from the 
ordinary short hypodermic needles to those 10 cm. in 
length. Nickel and platinum needles may be had, and by 
their longer life are worth the difference in the purchase 
price. 

The Preliminary Treatment of the Patient who 
is to Receive the Infiltration (Terminal) or the 
Conductive (Regional) Anaesthesia. — An hour before 

17 



258 ANiESTHESIA 

operation a dose of morphine gr. Ye and scopolamine gr. 
1/200 should be given. 

The operation, no matter how trivial, should be invaria- 
bly done with the patient lying down. 

The patient should have a cup of soup or milk. It is 
best not to operate on an empty stomach. 

It will be readily understood that the proper employ- 
ment of suggestion is most important. This applies not 
only to the immediate treatment of the individual but 
especially to the provision of a proper environment, quiet, 
courtesy and the banishment of disagreeable sights. 

Every effort should be made to distract the attention 
of the patient. If one is acquainted with his habits and 
sphere of life, conversation proceeds more freely. A sip 
of water or vichy may be permitted now and then. Some 
operators allow their patient to smoke. 

Operations done under local anaesthesia need not be 
hastened. Great care and gentleness should be exercised 
in the use of retractors and in sponging. 

The Administration of Infiltration (Terminal) 
Anaesthesia. — A syringe is filled with the desired solu- 
tion, and the needle is introduced just beneath the skin 
and nearly parallel to it. The solution is forced into the 
tissue and should form a small, blanched elevation or weal. 
The needle is withdrawn and reintroduced into the border 
of this weal, not into a portion of the uninfected skin. 
If one follows the practice of reintroducing the needle 
each time into the weal, the only pain which the patient 
will experience will be the initial introduction. It is sug- 
gested that novocaine solutions be dyed so that the limit 
of its penetration into the tissue may be easily seen. When 
the desired area has been injected, the skin will be found 



USUAL METHODS 



259 



to be anaesthetized. Great care should be exercised to see 
that the incision does not extend beyond the anaesthetized 
area. The anaesthesia thus produced will last for two or 
three hours. Tissues, whose sensitiveness we know to be 
acute, should be carefully injected before they are touched 
with the knife or sponged (Fig. 114). 




LEAST SENSITIVE 

fat 
muscle <> 
tendons 
fascia 

visceral 
peritoneum 
bone 
carti/aqe, 



MOST SENSITIVE 



skin 
par/<z fa/ 

per/foneum 

nerv<zs 

b/ooa' 

vesse/s 



pertosfcan? 

Synovia/ 
mucous 
membrane, 
(art/cu/ar surface) 

Fig. 114. — Relative sensitiveness of tissues. (Modified from Cunningham's Anatomy.) 

The skin is ever} r where sensitive. 

The fat, muscles, tendons and fascia where nerve 
trunks and blood vessels are not included, are insensi- 
tive. 

The parietal peritoneum is very sensitive, but the vis- 
ceral peritoneum is insensitive. 

Periosteum and synovial membranes are very sensi- 
tive. 

Bone and cartilage are not sensitive. 

The Administration of Conductive or Regional 
Anesthesia. — Conductive anaesthesia implies a precise 
knowledge of the distribution of the nerves supplying the 
part to be operated on. Perineuria! injections are quite 
easily made. The time required for anaesthesia and the 
strength of the solution depend upon the size of the nerve 



260 ANAESTHESIA 

to be blocked. Strong solutions .5 to 1 per cent, cocaine 
are used about large trunks. By the employment of con- 
ductive ansesthesia, boils or ulcers may be blocked at a dis- 
tance and the incision or the excision of the same rendered 
painless. In endoneural injections the nerve should be 
dissected out and the needle pointing centrally thrust into 
it. The solution is then injected until the nerve swells. 
If the needle points peripherally, pain from traction is 
likely to occur. Pain is not marked upon injection and 
the conductivity is immediately and completely blocked. 

Healing in Both Conductive and Terminal 
Methods. — The accidental use of saturated saline solu- 
tion instead of normal saline has occasioned sloughing of 
the tissues. Some operators have reported delayed union 
where quinine and urea have been employed. As a rule, 
however, the healing is rapid and entirely satisfactory. 

The combined Local and General Ancesthesia Technic 
of Anoci Association as advocated by Dr. Crile of Cleve- 
land has been discussed on page 244. 



SPINAL ANESTHESIA 
CHAPTER XII 

GENERAL CONSIDERATION 

Spinal anaesthesia is that type of anaesthesia in which 
both the central nervous system (the spinal cord) and the 
peripheral nervous system are brought under the influence 
of the anaesthetic. 

This type of anaesthesia is used freely upon the Euro- 
pean continent. 

Spinal anaesthesia is brought about by injecting the 
anaesthetizing solution directly into the subarachnoid 
space. Here it mixes with the cerebrospinal fluid. The 
cerebrospinal fluid, containing the dissolved anaesthetic, 
may then be said to act as does conductive or regional 
anaesthesia, where perineuria! injections are employed (see 
page 259). 

The situation in this case is quite different, however, 
from that of ordinary local anaesthesia for the following 
reasons : 

1. The entire dose must be given at once. 

2. The injection is made into a diffusible medium, i.e., 
into the cerebrospinal fluid. 

3. The effects sought for and ordinarily produced are 
limited to a loss of the sense of pain. The appreciation 
of heat and cold and of pressure and traction are often 
retained. 

4. Nerve cells, as well as fibres, are exposed to the 
action of the anaesthetic. 

261 



262 ANESTHESIA 

The puncture of the spinal cord and the injection of 
the analgesic solution imply a knowledge of the anatomy 
of the part. While the dose may be repeated, if the first 
dose proves inefficient, it cannot be repeated ad libitum. 
On the other hand, it is impossible to withdraw an overdose. 

A solution of a lower specific gravity than the cerebro- 
spinal fluid is known as a diffusible solution. These solu- 
tions are usually made up of the anaesthetic drug, water 
and alcohol. Such diffusible solutions are employed for 
analgesia required above the point of injection, i.e., for 
neck and head operations. We mention this type of solu- 
tion only to condemn it. 

When the operation is to be in the lower limbs a solu- 
tion containing glucose is sometimes used. The addition 
of glucose is for the purpose of increasing the specific 
gravity of the injected solution. Such a solution is known 
as a non- diffusible solution. 

The cerebrospinal fluid is a secretion of the choroid 
plexus and the ependymal membrane (membrane lining 
the central canal of the cord). The amount of the fluid 
varies from 50 to 150 c.c. The specific gravity is vari- 
ously estimated at 1.004 to 1.007, increasing with the age 
of the patient. The cerebrospinal fluid is constantly in 
motion and under a pressure varying from 50 to 150 mm. 
of water. 

The diffusion of the injected fluid depends upon the 
concentration and the pressure with which the injection is 
made. The diffusion occurs very rapidly where marked 
pressure is made. 

The head down position also increases diffusion, par- 
ticularly in the case of a solution heavier than the cerebro- 
spinal fluid. 



SPINAL ANAESTHESIA 263 

Unless one is prepared for analgesia, loss of pain sense 
rather than anaesthesia, loss of all sensation, the active 
responses to traction and preparation of the patient with 
hot water are likely to prove disturbing. It is unwise, how- 
ever, to ask the patient whether or not he still feels pain, 
as pressure may be so interpreted by a nervous individual. 

The fact that the nerve cells, not only in the cord but 
in the base of the brain as well, are exposed to the action 
of the anaesthetic solution, introduces a complicating factor 
and one which increases the danger of the general employ- 
ment of the method. Degenerative effects have shown 
themselves in the form of permanent paralysis and in 
paresis. 

By means of spinal anaesthesia or analgesia it has been 
possible to render the entire body insensitive to pain. 
Operations upon the head and neck as well as upon the 
extremities have been done painlessly. High analgesia, 
above the diaphragm, occurs where a concentrated solution 
has been given under pressure. Because of the danger 
of paralysis of the respiration, analgesic effects above the 
umbilicus should not be tolerated. 

The method has been used, and with satisfaction, in 
children. 

Apparatus 

1. Suitable syringe and two cannulas. 

2. Solution for injection. 

3. Ethyl chloride spray or local anaesthesia accessories 
for novocaine injection of the skin. 

4. Hypodermic of strychnine 1/30 and camphor in oil. 

5. Sterile adhesive or collodion for sealing puncture. 
1. Complete set of suitable syringes and needles may 

easily be had (Fig. 113). 



264 ANAESTHESIA 

2. Since cocaine and stovaine solutions have given way 
to the less toxic novocaine and tropacocaine, it will hardly 
be to our advantage to consider the former. Vials of 
novocaine, 5 per cent, solution, containing 3 c.c. each, will 
be found satisfactory. 

The novocaine tablet C, also for sale, is very con- 
venient. The minimum dose is 2 c.c, average dose 2.5 c.c, 
maximum dose 3 c.c. 

Vials of tropacocaine 5 per cent, solution, containing 
1 c.c. each, are on the market and will be found satisfactory. 
The minimum dose, one vial 1 c.c, maximum dose, two 
vials 2 c.c. 

Both of the above solutions contain adrenalin. 

When the syringe and needles are boiled one should 
be careful to have no soda in the water, as an alkaline solu- 
tion destroys the solutions of both the above drugs. 



CHAPTER XIII 
THE ADMINISTRATION 

It is perfectly feasible to carry out the administration 
without any preliminary preparation whatever. 

When possible, however, psychic treatment should be 
employed, every means being used to gain the confidence 
of the patient. It is advisable to give a dose of morphine 
gr. y% and hyoscine 1/200 an hour before operation. 
StrycPmine gr. 1/60 and nitroglycerine gr. 1/100 may be 
used to advantage. It is not necessary that the patient 
fast. 

The most satisfactory site of injection is between the 
third and the fourth lumbar vertebrae directly in the middle 
line (Fig. 117). The object of this site of injection is to 
immediately engage the ligamentum muscle. This facili- 
tates the direct entrance into the canal. 

This point may be found as follows : With the patient 
sitting up in a slouching posture, draw a line connecting 
both iliac crests. This line will cross the spinous process 
of the fourth lumbar vertebra (Fig. 116). The point 
of injection is then just above this line. The site of 
injection having been located, the area is then painted 
with iodine and a slit sheet placed over all. The patient 
w T ith the arms folded across the abdomen is instructed to 
lean forward bending the neck on the chest. This atti- 
tude serves to increase the spaces between the spines. The 
skin is now sprayed with ethyl chloride and a small nick 
made with a scalpel. The cannula with the mandril or stylet 

265 




Fig. 115. — The relations of the lumbar and dorsal interspaces to the crests of the ilia and lower 
ribs. (Steel, International Clinics.) 



THE ADMINISTRATION 



267 




Fig. 116. — Localization of the spinal interspaces. With the patient bent forward, a towel stretched 
between the iliac crests passes through the spine of the fourth lumbar vertebra. The first lumbar in- 
terspace is opposite the tip of the last rib. (Steel, International Clinics.) 



268 ANAESTHESIA 

in place is then inserted. The needle is directed forward 
and inward. One feels a sense of resistance followed by a 
sudden pop as the needle enters the canal. The mandril 
should then be withdrawn. If the needle is in the canal 
fluid will escape. If no fluid escapes one should replace 
the mandril again, insert and withdraw until, upon the 
partial withdrawal of the mandril, fluid escapes. Ten or 
fifteen drops of cerebrospinal fluid may be permitted to 
escape out of the end of the cannula. The syringe, loaded 
with the solution, novocaine or tropacocaine, is then 
attached and a little of the cerebrospinal fluid is with- 
drawn (Fig. 119). The syringe with the mixture is then 
detached to see that the needle is still in the canal. If 
spinal fluid flows out the syringe may be reattached and 
the injection made under moderate pressure. The greater 
the pressure the higher will be the anaesthesia. The patient 
should then be placed in the semi-sitting position. The 
procedure is completed by sealing the wound by adhesive 
or collodion. 

Shortly after the injection the following symptoms 
may be expected : Tingling of the feet, a sense of general 
malaise, nausea and vomiting. These symptoms may be 
marked or of no consequence. Following the tingling in 
the feet, analgesia and loss of motor power will make their 
appearance beginning below and extending upward. Pal- 
lor and perspiration are occasionally seen. At the first 
appearance of any symptom, however slight, the patient 
should receive immediately a hypodermic injection of 
strychnine gr. 1/30. 

An overdose may be treated by inhalations of ether 
carried to the period of excitement. 



THE ADMINISTRATION 




Fig. 117. — The point of skin puncture is anaesthetized by freezing; this is not necessary if 
fine needle is used. (Steel, International Clinics.) 



270 



ANAESTHESIA 




Fig. IIS. — The needle is introduced in the middle line forward and inward. (Steel, International 

Clinics.) 



THE ADMINISTRATION 



271 




Fig. 119. — As the dura is pierced, the cerebrospinal fluid escapes and maybe collected in test- 
tube for further study. (Steel, International Clinics.) 



The Advantages of the Method 

1. When acting satisfactorily it insures a quiet field of 
operation. 

2. Reduces the amount of after-sickness. 

3. The necessary apparatus is comparatively simple. 

4. May prove of value where there is an absolute con- 



m 



ANAESTHESIA 




Fig. 120. — The syringe containing the proper dose of stovaine is attached to the needle and 
slowly injected. (Steel, International Clinics.) 



THE ADMINISTRATION 273 

traindication to an anaesthetic, or where one is confronted 
with an inexperienced anaesthetist and a bad subject for 
general anaesthesia. 

The Disadvantages of the Method 

1. An overdose cannot be withdrawn. 

2. The duration and the degree of the analgesia or the 
anaesthesia cannot be depended upon. 

3. The amount of the drug necessary to produce the 
desired result is not absolutely known. 

4. There is at times incomplete muscular relaxation. 

5. There is danger in the injection of a heterogeneous 
fluid into the spinal canal. 

6. Its expert use requires experience which must be 
gained by trials upon patients who present no special indi- 
cations for the method. 

7. There is danger of subsequent paresis and local or 
general paralysis. 

8. The induction is frequently unpleasant for the 
patient and the persistence of consciousness may prove 
undesirable. 



PART II 

BEARING UPON FACTORS INCIDENTAL TO THE 
ACTUAL ADMINISTRATION OF THE ANAESTHETIC 



CHAPTER XIV 

PRELIMINARY MEDICATION IN ANESTHESIA 

By preliminary medication we mean that medication 
which is given before the anaesthetic has been induced, 
Drugs so administered are usually given hypodermically P 
for by this method they act more speedily and with greater 
constancy. 

Drugs,, Doses and Time of Administration 
The most common preliminary medication is by mor- 
phine and atropine. The ordinary dose of morphine is 
grs. %, of atropine grs. 1/150. If indications call for a 
smaller dose, the above standard tablet is dissolved in a 
hypodermic syringe, and one-half or two-thirds of the 
entire solution is given. The usual time of administration 
is twenty minutes before operation. Some prefer a two 
hour interval. 

The next most common preliminary medication is that 
by morphine and scopolamine (hyoscine). Scopolamine 
and hyoscine are thought to be identical. The maximum 
dose of morphine is % grs., of hyoscine 1/100 grs. The 
dose ordinarily administered is two-thirds of the maximum 
dose. The time of administration is one hour before 
operation. A dosage chart will be found on Page 360. 

Preliminary medication is sometimes given by mouth 
in the form of triple bromides ; ten grains every four hours 
for three doses before operation may be given, where the 
patient is unusually nervous and apprehensive. Veronal, 
the evening before the operation, in doses of 7 grs. dis- 
solved in hot milk will be found of value, where insomnia 
is to be expected. 

277 



278 ANAESTHESIA 

General Considerations 

The entire question of preliminary hypodermic medi- 
cation appears to depend upon whether the administration 
of the anaesthetic is to be the open or closed method. In 
other words, the situation is dependent upon the amount 
of rebreathing which the patient experiences. Those who 
have written for and against the use of preliminary hypo- 
dermic medication do not sufficiently emphasize the method 
which they customarily employ in the administration of the 
anaesthetic. Anaesthetists, who use the open or semi-open 
drop method to the exclusion of the closed method, natu- 
rally see the maximum ill effects. On the other hand, 
those who habitually make use of strictly closed methods, 
see untoward phenomena so infrequently that they are 
liable to discount their occurrence. If the influence of 
rebreathing or C0 2 stimulation upon narcotized subjects 
be more fully appreciated, this confusion of judgment 
will not so frequently occur. 

Experiments upon dogs and other small, hairy animals, 
by virtue of the more extensive functions of the lungs in 
throwing off moisture, heat, etc., render experiments 
directed to respiratory phenomena in human beings of less 
value than was formerly supposed. In glancing over the 
materia medica, we find the action of morphine, atropine 
and scopolamine to be most complex. Almost every sys- 
tem and every organ is affected. To attempt to catalogue 
these effects, or to attempt to neutralize supposed effects 
by other supposed effects is likely to result in confusion. 
Where the action of these drugs may be calmly studied in 
the normal subject, complicated only by age, idiosyncrasy, 
dosage and purity of the drugs used, our task is sufficiently 
difficult. Where, however, we superimpose upon these 



PRELIMINARY MEDICATION IN ANAESTHESIA 279 

complications an anaesthetic, incidental respiratory obstruc- 
tion, the absence or presence of rebreathing, operative 
trauma, posture of the patient and the difficulty of calm 
observation, our problem becomes very complex indeed. 
To depend solely upon the pharmacological action of a 
drug, or upon a combination of drugs, to determine our 
attitude toward preliminary hypodermic medication in 
anaesthesia is misleading. 

Above the mass of information which lends itself for 
observation in such cases, there appear certain facts which 
are quite constant and which respond to certain forms of 
treatment. 

Where preliminary medication is used : 

(a) The respiration is depressed. This depression 
often tends to delay the period of induction. If the open or 
semi-open drop method is used, this depression continues 
and becomes more pronounced as anaesthesia progresses. If 
the closed method is used, and rebreathing freely permitted, 
the respiration is seldom depressed, the quality depending 
upon the amount of rebreathing permitted. 

(b) If atropine is included in the preliminary medica- 
tion, the secretions are checked. The saliva and mucus 
in the throat are markedly diminished or absent, even in the 
face of a stormy induction. 

(c) The excitement, incidental to the stage of induc- 
tion, is diminished. This is particularly true of athletes 
and alcoholics. The psychic fear of operation is also 
largely dispelled. 

(d) The amount and concentration of the anaesthetic 
used may be reduced. 

(e) It is said that if morphine is given before opera- 
tion, the acidosis consequent to the operation is diminished. 
If given after operation, no such beneficial effect follows. 



280 ANESTHESIA 

(/) After the return of the reflexes, the patient often 
sinks into a deep sleep which delays the return of conscious- 
ness. This effect is not altogether undesirable. Where 
an open or semi-open administration has been carried on, 
the rate of the respirations at this stage is likely to drop 
alarmingly. Where rebreathing has been permitted this 
is not so likely to take place. 

(g) Susceptible patients may vomit more or less fre^ 
quently from the use of morphine per se. 

Some surgeons give morphine and atropine just before 
the conclusion of the operation, with the view of sparing 
the patient post-operative pain. Such treatment can do 
no harm where the open method is employed. When the 
closed method is in use, however, such medication is not 
used to the best advantage. A much more satisfactory, 
all-round result is attained when given twenty minutes 
before operation. If, during the course of an open method 
administration, the respirations become slow and shallow, 
the condition becomes a difficult one to meet. Some 
method of rebreathing must be resorted to. Should the 
same condition occur in the course of a closed adminis- 
tration, a ready improvement will be noted upon increas- 
ing the rebreathing, and using oooygen with the gases 
rebreathed. We not uncommonly meet the following 
conditions : 

A large, full-blooded patient is given preliminary medi- 
cation. The stage of induction proceeds slowly, for the 
respirations are shallow. The shallow respirations further- 
more induce a variable amount of duskiness. Free re- 
breathing into the closed apparatus cannot be carried on 
because, the more the patient rebreathes, the more dusky he 
becomes. He cannot be carried satisfactorily upon an 
open method because the respirations are so shallow that he 



PRELIMINARY MEDICATION IN ANESTHESIA 281 

does not get sufficient ether. If oxygen be admitted to the 
rebreathing bag, the difficulty will be entirely obviated for 
then rebreathing may be freely employed. The respira- 
tions become deep and the color immediately clears. This 
treatment is not mere theory but constant practice. 

The Detailed Effect of Preliminary Morphine and 
Atropine upon the Signs of Anaesthesia, When 
Ether by the Closed Method is Used 

Induction. — The period of excitement is short and 
mild in character. 

The period of rigidity may be shortened or protracted, 
depending entirely upon the character of the respiration. 

The period of relaxation. The duration of this stage 
is also dependent upon the character of the respiration. 
In a general way it may be said that the stage of induc- 
tion is smoother but not always shorter. 

Respiration. — Usually more shallow and slower. Does 
not respond as readily to the stimulating effect of ether. 

Color. — Largely dependent upon the character of the 
respiration. 

Relaxation. — Rigidity may be persistent. Ordinarily 
muscular relaxation is rapid and complete. Relaxation of 
the upper lid and masseteric relaxation appear early. 

'Eyes. — Eyeballs become fixed soon after consciousness 
is lost. The light reflex is unaffected. The conjunctivo- 
palpebral and corneal reflexes soon disappear and are 
characteristically sluggish. The pupils are less likely to 
respond to sympathetic stimulation and widely dilate, as 
is occasionally the case where morphine is not used. They 
are frequently pin point from the start. 

Pulse. — Of no special significance unless unusually 
slow. 



282 ANESTHESIA 

Maintenance. — Respiration. — If rebreathing Is prop- 
erly employed there may be little difference noted during 
this stage. The respirations do not respond as readily to 
an increase or decrease of ether where morphine is em- 
ployed. The rhythm may be more or less affected,, even 
in the presence of normal rate and amplitude. 

Color. — There may be a persistent tendency to duski- 
ness. This can only be properly relieved by the use of 
rebreathing and oxygen. It should be recalled that duski- 
ness does not necessarily mean an excess of carbon dioxide 
(see page 298). 

Relaxation. — If the relaxation is once complete it has 
a tendency to remain so. Masseteric relaxation is usually 
maintained with ease. 

Eyes. — Eyeballs remain fixed. Rolling eyes need 
not cause as much concern as where morphine is not 
used, for a lighter anaesthesia may be carried with less risk 
of the patient " coming out." The light reflex may be 
sluggish or lost. The corneal reflex often fails to act in 
the usual satisfactory manner, and is sluggish or absent 
out of proportion to the depth of the anaesthesia. The 
pupils are almost always contracted, sometimes pin point. 
Dilated pupils, where morphine has been used, almost 
always mean a profound degree of anaesthesia . 

Pulse. — The pulse is ordinarily little affected by the 
operative trauma, even in a comparatively light anaesthesia. 

Recovery. — Respirations. — Characteristically shallow 
and occasionally irregular. Between the return of the 
reflexes and return of consciousness the rate may drop to 
six or eight a minute. 

Color. — Very likely to be unsatisfactory, especially if 
the respiration has been depressed throughout. 

Relaxation. — Complete and persistent. 



PRELIMINARY MEDICATION IN ANESTHESIA 283 

Eyes. — Motion of eyeballs begins early. The light 
reflex and the corneal reflex continue sluggish for some 
time. The pupil has a tendency to remain pin point. 

Pulse. — Not characteristic. 

When the open method is employed with morphine and 
atropine as preliminary medication, the untoward signs and 
symptoms, which are observed with the closed method, are 
aggravated. The respiration in particular is likely to 
fail. Induction is prolonged, maintenance is often a 
source of anxiety and recovery is ordinarily delayed. 

Where scopolamine is added to the morphine, the 
depressing effect of the latter is augmented. It is a 
dangerous practice to employ preliminary medication by 
morphine and scopolamine where the open or semi-open 
method is to be used. Where the closed method is em- 
ployed, with such preliminary medication, we are exposing 
the patient to more than ordinary risk. 

Preliminary Medication Where Nitrous Oxide and 
Oxygen is the Anaesthetic 

The use of preliminary medication by morphine and 
atropine and occasionally by morphine and scopolamine is 
positively necessary where nitrous oxide and oxygen are 
used alone, and where a smooth and prolonged anaesthesia 
is desired. When ether is employed in conjunction with 
these gases, the need of preliminary medication is not quite 
so imperative but is of distinct benefit. There is of course 
no choice between the open and closed method where these 
gases are employed. The closed method must be used. 
Where a continuous flow and little, if any, rebreathing is 
used, the open method may be simulated. With such a 
method it seems unwise to employ scopolamine as a routine. 

If morphine and scopolamine are used, the return to 



284 ANESTHESIA 

consciousness is delayed. Where indicated, however, it is 
very satisfactory. 

Since the signs of anaesthesia, when morphine and 
atropine or morphine and scopolamine are used with 
nitrous oxide oxygen anaesthesia, are nothing more or less 
than the typical gas oxygen anaesthesia described on page 
218, no special analysis is necessary. 

Where chloroform or ethyl chloride are used to induce 
or maintain anaesthesia, preliminary medication should not 
be used. 

Preliminary morphine and atropine or morphine and 
scopolamine are contraindicated : 

Where the open method is used. 

In the extremes of age. 

Where idiosyncrasy to the drugs exists. 

Where oxygen cannot be conveniently had. 

When the anaesthetist is inexperienced. 

Where the after nursing promises to be inefficient. 

Preliminary medication is indicated. — In nitrous oxide 
oxygen, and nitrous oxide ether anaesthesia. 

In the athletic, the alcoholic and heavy smokers, partic- 
ularly women. 

For neck and throat cases in adults where intratracheal 
anaesthesia is not available. Goitre cases and tonsils and 
adenoids. 

Whenever one wishes to reduce the amount of the anaes- 
thetic used, i.e., acidosis, diabetes, etc. 

Where the patient is neurotic or hysterical, for psychic 
reasons. 

When the post-operative pain promises to be extreme ; 
burns ; rectal cases. 

In all local anaesthesia. 

In morphine habitues in order to allow these patients 
to withstand the strain of the operation. 



CHAPTER XV 

THE POST-OPERATIVE TREATMENT OF THE 

PATIENT 

THE DUTIES OF THE NURSE BEFORE, DURING AND 
AFTER ANESTHESIA 

We can scarcely overestimate the influence for good 
which the nurse may exercise upon the patient awaiting 
operation. A woman, especially, leans very heavily upon 
those about her for sympathy in this, her time of need. A 
nurse, who cannot enter somewhat into the patient's point 
of view, will entirely fail in the good which she may do. 
A patient, who is rated in the nurse's mind as simply a 
kidney case, a neck case or some other kind of a case, will 
not fail to feel the situation keenly. As a result, she will 
feel the necessity of protecting herself against evils, vague 
reports of which have reached her before she entered the 
hospital. This spirit of distrust or apprehension, even 
though having no foundation, will be very real to the 
patient. Her confidence must be secured, she must freely 
and willingly relinquish herself into the hands of those who 
offer her relief. We all like to hear that we have engaged 
the best surgeon, or the kindest and most careful anaesthe- 
tist in the city, and while we may be glad to hear that our 
case is unusual, it is even better news to learn that it is 
well within the skill of the surgeon, whom we have engaged. 

The nurse should never permit the suspicion of failure, 
or the shadow of death, which may lurk in a neighboring 
room, to enter the mind of her patient ; and by her patient, 
we do not limit ourselves to the private case, but we wish 
to emphasize more particularly the needs of the case in 

285 



286 



ANESTHESIA 



the ward. For those who wish to enter into the point of 
view of the patient, we have prepared a chapter which 
appears at the end of this volume. 

The nurse should inquire into the history of the patient, 
more particularly in regard to her previous anaesthesias and 




■* ;S.-. 



Fig. 121. — Nurse grasping patient's wrists. 



her reaction to morphine and other drugs. The condition 
of the teeth should always be inquired into, and false teeth 
should be removed. She should become perfectly familiar 
with the various table positions necessary for the best 
operative exposure ; i.e., Trendelenburg, Simms, lithotomy, 
etc. (see page 37). If the operation is to be in the 



POST-OPERATIVE TREATMENT OF PATIENT 287 

patient's home, the patient lying in her own bed, the nurse 
should realize the importance of the anaesthetist's control 
of the head (see page 23). Once the anaesthetist has 
taken charge of the patient, it is best that the nurse confine 
her conversation with the patient to as few words as 
possible. 

During the course of the anaesthesia, it is always best 
for the nurse to refrain from all remarks as soon as the 
induction has begun. Desultory conversation heard by 
the patient is likely to make her feel that she is not receiv- 
ing the proper attention. At this time hearing is par- 
ticularly acute. (It is bad taste for the nurse to assume 
the responsibility of the patient's welfare until the latter 
has lost the sense of hearing. ) 

If the patient begins to struggle, throwing the arms 
above the head, the nurse should grasp the wrists, never 
the hands (Fig. 121). If she clasps the hands, as is fre- 
quently done, the patient is very likely to crush her fingers 
in a vicelike grip, or to dig the finger nails into her palms. 
Struggling movements, unless they interfere with the 
anaesthetist, should be guided rather than repressed. By 
such treatment they will subside much more quickly. 

The nurse should be constantly awake to the needs of 
the anaesthetist and remain in sight as much as possible. 
The anaesthetist often dislikes to call for ether, towels, etc., 
as this has a tendency to upset the surgeon, who thinks 
something serious has gone wrong. 

THE DUTIES OF THE NURSE AFTER ANESTHESIA 
Strictly speaking, the nurse takes part in the anaes- 
thesia inasmuch as she usually has charge of the patient 
before the stage of recovery has finished. She should be 



288 ANAESTHESIA 

very familiar with the duties incumbent upon her during 
this interval between the return of the reflexes and the 
return of consciousness. At this time she is likely to meet 
with the following difficulties : Vomiting , cyanosis, respira- 
tory failure, hemorrhage, circulatory shock, hysteria and 
protracted unconsciousness. 

Vomiting. — Without doubt the most common difficulty 
which the nurse will meet is vomiting. There are at least 
three kinds of vomiting, which may be recognized : Vomit- 
ing, caused by ether, reflex vomiting from the intra-abdomi- 
nal manipulations, which have taken place, and vomiting 
due to morphine. 

The vomiting which is due to ether usually begins 
before consciousness has fully returned, and lasts for hours 
and even days. This form of vomiting is usually accom- 
panied by nausea. Patients, who complain of the odor of 
the ether, and who frequently vomit after operation, often 
do so because of the odor of the ether in their own expira- 
tions. This type of case will often experience marked 
relief, if permitted to smell of some strong perfume, 
essence of orange, or vinegar applied by means of a gauze 
sponge laid over the upper lip (p. 80) . This treatment is 
so simple that it should be applied, as a routine, to every 
case recovering from anaesthesia. Those cases, which suffer 
from persistent vomiting, are often relieved by having the 
stomach washed out with a warm, alkaline solution. They 
are usually intolerant of fluids by mouth, but they will 
often retain champagne or ginger ale. 

Vomiting caused by reflexed pain is quite common, 
especially where ovarian work has been done. Any manip- 
ulation, however, involving the parietal peritoneum is 
likely to be followed by this form of disturbance. The use 



POST-OPERATIVE TREATMENT OF PATIENT 289 

of novocaine, quinine and urea as a nerve block during 
the course of the operation will do much to control this 
type of vomiting. Pre-ansesthetic narcotics are also val- 
uable in that they reduce the sensitiveness to pain. When 
vomiting takes place as a result of reflex irritation, the 
patient does not complain of the odor of the ether, as is 
usually the case in the former type. 

Vomiting, which occurs as the result of the administra- 
tion of morphine, is quite frequent, particularly where the 
anaesthetic is gas oxygen. This type of vomiting is usu- 
ally unaccompanied by nausea. It resembles somewhat 
that which is seen in cerebral irritation, or that which may 
be induced by apomorphine. This form of vomiting is 
the least annoying to the patient. The author recalls a 
case in which the patient, in the midst of such an attack, 
remarked that " she did not mind this," that it was nothing 
like the vomiting that she had experienced after ether. 

In order to ascertain the best position in which to place 
a patient who is vomiting, the nurse should recall the pos- 
ture of conscious patients, who are at liberty to place 
themselves to the best advantage. Such patients, it will 
be recalled, look directly forward, not to the side, and 
extend the head on the neck. Hence, when a patient, who 
is not yet conscious, begins to vomit, he should be placed 
on his side. If the head is turned to the right, the left 
shoulder be raised. The head may be slightly extended 
by supporting the brow with one hand. Patients recover- 
ing from operations on the nose and throat, particularly 
children who have had their tonsils and adenoids removed, 
should be placed in the Simms or the prone position (see 
page 44, Fig. 25). 

Cyanosis. — Cyanosis is almost always due to some 

19 



290 ANAESTHESIA 

form of respiratory obstruction. It is ordinarily brought 
about by one of two causes ; masseteric spasm or vomiting. 

Masseteric spasm often occurs in alcoholic and full- 
blooded individuals. In these cases the tongue becomes 
clenched between the teeth and efficiently blocks respiration 
through the mouth. If to this condition there is superim- 
posed a partial or complete nasal obstruction, the condition 
becomes serious. A communication must be established 
between the pharynx and the outside air. If the teeth 
cannot be readily separated by the handle of a spoon or by 
the wedge (Fig. 13) (one of which should be the property 
of every nurse) , then a catheter should be slipped into each 
of the nostrils for a distance of about six inches. A small 
size rectal tube may also be used. These tubes before 
introduction should be lubricated by the saliva, which is 
running out of the patient's mouth. Needless to say the 
responsibility of such a complication should be shared with 
the surgeon, if the latter is within ready call. Experience 
alone will provide the confidence necessary in dealing with 
such cases. 

Cyanosis due to obstruction incidental to vomiting usu- 
ally occurs in the first period of recovery. When the 
reflexes have fully returned there is much less likelihood 
of this difficulty. Cases of intestinal obstruction, tonsils 
and adenoids, or gastro-enterotomies are most likely to 
suffer from this complication. The treatment consists of 
extending the head and wiping the vomitus from the mouth 
and pharynx. 

During the stage of recovery the patient lies flat in bed, 
no pillows being employed. When consciousness returns, 
and vomiting has ceased, elevation of the head by one or 
more pillows is grateful to the patient. 

Cyanosis occurring with dyspnoea would suggest a 



POST-OPERATIVE TREATMENT OF PATIENT 291 

cardiac lesion, or possibly a pulmonary embolus. In view 
of such a complication the surgeon should immediately be 
called. 

Respiratory Failure. — Where morphine is used as 
a preliminary to anaesthesia, particularly when the open 
drop method with ether is employed, the patient may suf- 
fer from respiratory depression. In this case the respira- 
tions become shallow and very slow. A nurse who sees 
this phenomenon for the first time may become very much 
frightened, as the respirations drop from 18 down to 6 or 
8 per minute. If the patient is conscious he should be 
roused by conversation. Instead of making every effort 
to increase the air he breathes, he should be made to breathe 
for short periods into a towel, or a rubber bathing cap. 
Such rebreathing will stimulate the respiration by virtue 
of the accumulated carbon dioxide (see page 300). The 
rebreathing should not be carried to a degree of duskiness 
or cyanosis. If oxygen is convenient much more satis- 
factory results may be had, as the rebreathing may then 
be protracted. The oxygen may be conveniently bubbled 
under the oiled silk cap into which the patient is made to 
rebreathe. Such cases often improve when given a hypo- 
dermic of atropine grs. 1/150. 

Hemorrhage. — Hemorrhage becomes evident in a 
small, rapid, running, thready pulse. Pallor is usually 
present and the forehead is covered with a cold perspira- 
tion. When this condition has begun in the operating 
room instructions are usually received to raise the foot of 
the bed (Shock position, see Fig. 123), as soon as the 
patient is returned to her room. This position improves 
the cerebral circulation. A Murphy drip or hypodermoc- 
lysis (fluid under the breasts) is often employed. If the 
condition is very pronounced air hunger will manifest 



292 ANAESTHESIA 

itself, the respiration becoming irregular, deep and sigh- 
ing. Such a case is usually in desperate straits. 

Circulatory Shock. — Circulatory shock is primarily 
a nervous phenomenon. It may be likened to syncope or 
fainting, carried to an extreme degree. The treatment 
consists in keeping the head low (Fig. 123) , applying heat 
to the trunk and extremities, and in giving strychnine 




Fig. 122.— The Fowler position. The head of the bed elevated. 

hypodermically. Enemas of hot coffee or coffee and 
brandy ( 2 Oz. ) are efficient. 

Hysteria. — Where, by virtue of improper preliminary 
treatment, the induction has been stormy, it is not unusual 
to find an equally stormy recovery. Neurotic, hysterical 
women, particularly if addicted to alcohol or drugs, may 
give a great deal of trouble. Every case must be individ- 
ualized. Such patients often bear large doses of morphine 



POST-OPERATIVE TREATMENT OF PATIENT 293 

well and can be quieted only by this means. Of greater 
importance, however, than the mere annoyance caused by 
such a condition are the suicidal tendencies which may sud- 
denly appear in such patients. How many of such have 
escaped the vigilance of the nurse and flung themselves 
from the nearest window to the courtyard below! While 
such extremes are uncommon, the possibility of a calamity 
of this nature should always be borne in mind. 




Fig. 123.— The Shock position. The foot of the bed elevated. 

Protracted Unconsciousness. — We may presume 
that a patient who comes from the operating room without 
having vomited since the conclusion of the operation, whose 
eyelids are separated, eyeballs fixed, and whose lower jaw 
offers no resistance when we open and close it, will not 
recover consciousness for some time. If the administra- 
tion of the anaesthetic has been such as to permit of an 
accumulation of the drug employed, i.e., by the rectal 



294 ANAESTHESIA 

method; the recovery will be much retarded. The use of 
morphine and scopolamine, or of morphine alone, often 
causes the patient to fall into a deep sleep after the reflexes 
have returned. If left alone they may sleep for four or five 
hours. This sleep can scarcely be ascribed to an uncon- 
sciousness from the anaesthetic. The return of consciousness 
should date from the moment the patient is capable of 
answering questions rationally. Unless roused, a patient, 
though fully conscious, will often dose with his eyes closed. 

If the respiration, color and pulse be satisfactory, it is 
of little advantage to awaken the patient. If conscious 
motion or speech do not return after two or three hours, 
however, effort should be made to rouse him. A patient 
who is a diabetic may never recover consciousness. 

The relative rate of recovery by different methods of 
anesthetization is shown below: 

Gas oxygen. Most rapid recovery. 

Gas oxygen ether. 

Gas oxygen ether and morphine and scopolamine. 

Incomplete anaesthesia by ether or chloroform. 

Complete anaesthesia with ether by the closed method. 

Complete anaesthesia with ether by the open method. 

Complete anaesthesia with ether by the closed method 
with morphine. 

Complete anaesthesia with ether by the open method 
with morphine. 

Complete anaesthesia with ether by the open method 
with morphine and scopolamine. 

Rectal anaesthesia — slowest recovery. 

While this table is subject to many influences, it may 
be used as a working basis to determine the time at which 
we may expect consciousness to return. 



POST-OPERATIVE TREATMENT OF PATIENT 295 

It is scarcely necessary to speak of the necessity of 
guarding against burns by hot water bags. As this mis- 
hap continues to occur, however, the warning can hardly 
be overemphasized. 

As soon as convenient, after the patient is placed in bed, 
the room should be darkened and all unnecessary noise 
incidental to arranging furniture and utensils should cease. 

Great care should be taken to see that the patient is 
not exposed to a draught. Exposure at this time may be 
followed by pneumonia or pleurisy. 

Stout, elderly people, who have suffered gall-bladder 
operations, are prone to develop congestion of the base 
of the right lung because of the restricted respiratory 
movements due to pain in this region. 

Goitre cases, in fact any neck case, should have the 
head elevated as soon as possible. This reduces the con- 
gestion of the part and allows greater freedom of the 
respiration. 

The diet is ordinarily ordered by the surgeon in charge. 
The rapidity of the return of consciousness and the free- 
dom from nausea and vomiting usually indicate the toler- 
ance for liquids and food. Ordinarily the first fluid given 
is champagne, ginger ale, albumen water or small quanti- 
ties of ice-water. Cracked ice will sometimes be retained 
when all else is rejected. Thin soups, eggnogs and small 
quantities of toast may follow in the course of twenty-four 
hours. At the end of another day a soft diet may be given. 
In a general way we may say that the sooner food is 
tolerated, the more rapid will be the convalescence. 

Patients, who are anaesthetized by nitrous oxide and 
oxygen in the morning, are so little affected that they often 
eat their regular meal in the evening. 



CHAPTER XVI 
CARBON DIOXIDE AND REBREATHING 

It is now quite generally accepted that the air which 
we exhale is not poisonous, that the organic matter which 
it contains amounts to practically nothing, and that the 
disagreeable sensations experienced in ill ventilated rooms 
are primarily due to increased temperature, moisture and 
by-products of perspiration. Exhaled carbon dioxide, 
accumulating under such circumstances, produces no un- 
pleasant effects until it has become sufficiently concen- 
trated to stimulate the respiration to greater frequency 
than normal. This stimulating effect takes place when the 
concentration has reached 4 per cento If the amount be 
further increased to 10 per cent, distress and dyspnoea is 
experienced. 

These findings become of great practical interest when 
applied to the individual who rebreathes his expirations 
from a bag. The effect of such rebreathing is practically 
limited to the accumulated C0 2 inhaled by the patient. 

To some the very idea of rebreathing one's own expira- 
tions is repellent. Such aesthetic objections may be met 
by the fact that ordinary respirations into the atmosphere 
are largely made up of gases rebreathed. With the ordi- 
nary, quiet inspiration only about 500 c.c. out of the 
total lung (vital) capacity of 3700 c.c. is fresh air. As a 
matter of fact then we rebreathe more than six-sevenths of 
the air which we use for respiratory purposes during quiet, 
unobstructed breathing. The matter of rebreathing into 

296 



CARBON DIOXIDE AND REBREATHING 297 

a bag becomes one of relative, rather than absolute 
difference. 

The untoward effects of C0 2 depend very largely upon 
the presence or absence of oxygen. Many of the evil 
effects ascribed to C0 2 per se may be traced to a deficiency 
of oxygen. While high percentages of C0 2 , 8 to 10 per 
cent, probably cause bad effects, even in the presence of 
sufficient oxygen, such effects by smaller amounts under 
similar conditions are open to question. The physiology 
of carbon dioxide has assumed such proportions that we 
can scarcely do more than indicate a few of the recent 
findings which apply to anaesthesia. 

Chemistry of Carbon Dioxide. — Carbon dioxide or 
carbonic acid gas is a colorless, suffocating gas, very solu- 
ble in water. It neither burns nor does it support combus- 
tion. When heated at high temperatures it breaks down 
into CO and O. Ordinarily it is a very staple compound. 
The atmospheric C0 2 is derived from the respiration of 
animals, combustion, fermentation, volcanic sources, manu- 
facturing processes (cement works, etc.) and from mines 
after explosions of fire damp. 

The origin of carbon dioxide and the condition in which 
it occurs in the blood. — One of the chief sources of carbon 
dioxide is muscular action; the general body metabolism 
furnishes the remainder. 

Carbon dioxide is distributed uniformly throughout the 
mass of blood. Part is in simple solution, part is in chemi- 
cal combination with the plasma, part is in chemical com- 
bination with the corpuscles. 

The carbon dioxide forms compounds with the alkaline 
bases in the blood, ]\ T a. K., etc. One of the most common 
compounds is that formed with sodium. When the tension 



298 ANESTHESIA 

of the carbon dioxide is increased, as in the active tissues, 
the equilibrium is disturbed and alkali is taken from the 
proteids and combines with the excess of C0 2 to form 
sodium bicarbonate. When the carbon dioxide pressure is 
reduced, as in the lungs, sodium bicarbonate dissociates in 
part, giving off C0 2 . 

Oxygen gas and carbon dioxide gas are as independent 
of one another as are carbon dioxide and nitrogen. They 
coexist in the same blood corpuscle without reaction of 
any kind. Haemoglobin nearly saturated with oxygen 
will take up carbon dioxide as though it held no oxygen in 
combination. It is thought that the oxygen unites with 
the pigment portion, and carbon dioxide with the proteid 
portion of the haemoglobin. While the amount of oxygen, 
which the haemoglobin contains, does not influence its 
absorption of C0 2 , yet the presence of carbon dioxide 
loosens, as it were, the combination between the oxygen and 
the haemoglobin, allowing the latter to flow to the tissues 
more readily. This tendency of the carbon dioxide to 
facilitate the liberation of oxygen may serve to throw light 
on the hitherto inexplicable fact that rebreathing is often 
of distinct clinical benefit to the anaesthetized patient. 

Cyanosis and Carbon Dioxide. — The presence or 
absence of cyanosis has nothing to do with the amount of 
carbon dioxide present in the blood. As has been stated 
above, carbon dioxide exists in the blood in the simple 
solution and in chemical combination with alkalies present. 
The blood depends upon the corpuscles for its color and 
these, as is well known, depend upon the amount of haemo- 
globin which is contained in the individual cell. The 
haemoglobin then is the element which controls the color in 



CARBON DIOXIDE AND REBREATH1NG 299 

the blood. When the haemoglobin is exposed to oxygen, 
oxyhemoglobin is formed. It is this compound that gives 
the blood its characteristic crimson hue. The color of the 
blood then depends entirely upon the amount of oxyhsemo- 
globin present. In the patient a reduction of this com- 
pound results in duskiness, a greater reduction in blueness 
or lividity. See Section on color, Page 97. 

Clinically one may cause a patient to rebreathe into a 
bag of oxygen until the carbon dioxide is so much increased 
as to cause severe dyspnoea; cyanosis, however, will not 
supervene. 

The Effect on the Respiration of Reducing Car- 
bon Dioxide and of Increasing Carbon Dioxide in 
the Conscious Subject. — Definition of Terms, — Apncea: 
A condition of no breathing. Acapnia: (low alkaline re- 
serve) A condition of diminished C0 2 in the blood, the 
cause of true apnoea. Dyspnoea: A condition of in- 
creased breathing. Hypercapnia: A condition of increased 
C0 2 in the blood, often the cause of dyspnoea. 

The Effect of Reducing the Amount of C0 2 in 
the Blood. — Rapid, deep breathing in the conscious in- 
dividual is often followed by a sense of lightness in the 
head. This gives rise to a condition of acapnia, which, 
if continued, results in apncea of varying degrees. In 
everyday life this experience is familiar to those who, upon 
going out of doors upon a clear, exhilarating, winter's day, 
breathe deeply ten or fifteen times and find their heads 
swimming at the end of this exercise. After having run 
some distance to catch a train, one often experiences the 
necessity of voluntary respirations for some moments fol- 
lowing the exertion. In this latter case, oxygen in abun- 
dance has been supplied by the increased rate and depth 



300 ANESTHESIA 

of the respiration, but the usual amount of C0 2 present 
has been reduced and one unconsciously feels that if the 
rate and depth of the respirations can be somewhat les- 
sened, that the distress following upon the exertion will 
more quickly pass away. 

The Effect of Increasing the Carbon Dioxide in 
the Blood. — The effect of increasing the amount of car- 
bon dioxide in the blood is seen in the simple experiment of 
holding one's breath. If at some indefinite time, in the 
course of a normal respiration, the breath is held, the neces- 
sity to breathe will appear at the end of half a minute or 
less ; if, however, the carbon dioxide be well rinsed out of 
the lungs by several deep respirations, the necessity to 
breathe may be postponed for double this time. The 
absence of oxygen and the collapse of the lung per se 
stimulate the act of respiration, but these elements may be 
eliminated in the following experiment : If one fills a small 
(one gallon) bag with pure oxygen gas and, after rebreath- 
ing several times into this, holds the breath at the end of 
an inspiration (lung distended, surplus of oxygen pres- 
ent), and takes the length of time during which it is 
possible to hold the breath, he will find that this time will 
be considerably less than the period of apncea possible if 
he inhales pure oxygen and exhales into the atmosphere 
holding his breath at the end of a series of forced inspira- 
tions. In the second case, the conditions are identical 
except that the amount of carbon dioxide in the circula- 
tion is reduced. By carrying out this technic, disposing 
of all possible C0 2 and filling the lungs with oxygen, the 
longest possible period of apncea may be obtained, the 
record being (see page 307) 10 minutes, 10 seconds. 

It is possible, therefore, by the simplest experiments to 



CARBON DIOXIDE AND REBREATHING 301 

show the effect of the reduction and the increase of carbon 
dioxide in the blood of the conscious subject. 

Where observations may be made upon unconscious 
subjects, the effects are more striking as there is no inter- 
ference by the will. 

The anaesthetized subject offers exceptional opportuni- 
ties to study the phenomena incidental to an increase or 
diminution of carbon dioxide in the respired air. Such 
observations may be made not only by the use of the closed 
method in which case the results are positive, but by the 
open method as well, in which case the effects of the absence 
of the necessary C0 2 become apparent. 

Where the Open Method is Used. — One of the most 
common results of the use of the open method is acapnia. 
If acapnia becomes marked, as is sometimes the case, dur- 
ing an induction where there is much excitement, the 
patient shouting, crying out or breathing rapidly and 
deeply, a definite period of apnoea may develop. The 
beginner, who sees his patient stop breathing shortly after 
a period of excitement in ether anaesthesia, becomes much 
upset and immediately starts artificial respiration. If this 
artificial respiration is ineffectual, as is frequently the case, 
it may not interfere with the normal return of the respira- 
tion. If, however, it be effective, it may, by increasing the 
acapnia, materially delay the return of the normal respira- 
tion. If the patient stops breathing following a period of 
dyspnoea from excitement, in the presence of normal color, 
pulse and eye signs showing a light anaesthesia, ether 
being the anaesthetic and morphine having been omitted, 
it is best to leave the patient alone. He will soon breathe 
of his own accord even though he be apnoeic for a full 



302 ANAESTHESIA 

minute or more. This phenomenon is very common in 
children. 

Acapnia during the stage of maintenance, the open 
method being used, is of quite common occurrence* Apncea 
at this time however, is more serious, and is often associated 
with cold perspiration and circulatory depression. 

Acapnia during the stage of recovery is not seen as 
frequently as during induction and maintenance. 

When the open drop method is used the prevailing ten- 
dency is apnoea from acapnia. When the semi-open drop 
method is employed this tendency is reduced in proportion 
to the amount of rebreathing permitted. 

Where the Closed Method is Used. — Where a strictly 
closed method is employed, such as is described on page 
132, one does not see the apnoea of induction which is com- 
mon to the open method, because there is no acapnia. On 
the contrary there is very likely to be dyspnoea from hyper- 
capnia. Where a gas induction is employed, the gas per se 
induces a dyspnoea which is superimposed upon that due 
to hypercapnia. The result is rapid, deep breathing. 
Rapid, deep breathing at this particular time enables one 
to quickly saturate the patient's blood with ether, in other 
words induction is quickly accomplished. Morphine by 
depressing the respiration usually diminishes this dyspnoea 
and frequently retards the induction. 

During the stage of maintenance, however, the dys- 
pnoea caused by the hypercapnia must be controlled. Un- 
less this is done the excessive breathing is likely to prove 
a menace to satisfactory abdominal manipulations. If one 
understands the cause of the excessive breathing, which the 
patient experiences, he can easily adjust this difficulty. 
The control of the respirations by reducing or increasing 



CARBON DIOXIDE AND REBREATHING 303 

the C0 2 by means of rebreathing is exceedingly interest- 
ing. A patient who is breathing deeply and rapidly may, 
in the face of an upper abdominal operation, be immedi- 
ately quieted by entirely emptying the rebreathing bag and 
filling it with oxygen and air; abdominal rigidity and 
excessive movement of the diaphragm being at the same 
time reduced to the minimum by the free use of ether. 

During the stage of recovery, after the removal of the 
face piece and rebreathing bag, the respirations will usu- 
ally drop in rate and depth from the absence of the arti- 
ficial C0 2 stimulation. Shallow breathing may follow 
for a few moments. This effect however, is not due to 
acapnia but from a reaction to over stimulation by the C0 2 . 

When the closed method is used, the prevailing ten- 
dency is dyspnoea from hypercapnia. If this is properly 
controlled it is beneficial in as much as it allows of more 
rapid introduction and withdrawal of the ether employed. 
In other words the condition of the patient is more pliable 
than where there is a tendency to apncea from acapnia. 

The tendency to dyspnoea where the closed method is 
used increases the safety of preliminary medication, the 
chief characteristic of which is depression. 

Where Nitrous Oxide and Oxygen is the Ancesthetic. — 
Where oxygen is added to nitrous oxide in a quantity suffi- 
cient to control asphyxia, the dyspnoea ordinarily seen 
when nitrous oxide is used alone is not apparent. The 
effect of rebreathing in such cases is much the same as 
with the closed method of ether administration. Gas oxy- 
gen being a less depressing type of anaesthesia, however, 
the effects of rebreathing are even more marked. 

Where a constant flow of gas oxygen is employed 



304 ANAESTHESIA 

without rebreathing (see page 233), we may expect to 
see the apnoea characteristic of the open drop method. Gas 
oxygen anaesthesia with excessive rebreathing becomes 
annoying by virtue of the very deep respirations experi- 
enced. The addition of a preliminary dose of morphine 
reduces the sensitiveness of the respiratory centre to stimu- 
lation ( C0 2 ) and, with this type of preliminary medication, 
more extensive rebreathing may be permitted. 

The type of case with which we have to deal determines 
very largely the extent to which rebreathing may be per- 
mitted. A full-blooded individual, who has not received 
preliminary medication, will tolerate little rebreathing 
throughout anaesthesia. On the other hand an anaemic 
individual, who has been permitted to rebreathe an atmos- 
phere of oxygen and ether, will appear to be stimulated 
rather than depressed by the experience. The author is 
convinced that the sicker, the more septic a patient is, the 
more are closed methods of administration indicated. In 
such cases rebreathing with oxygen almost always appears 
to improve the general condition. The normal, vigorous 
individual at the end of an anaesthetic by the closed method 
is almost always in a better general condition than if he 
had suffered anaesthesia by the open method. ' The color 
is invariably better, the pulse shows less depression and 
the body heat is retained. The beneficial effect of rebreath- 
ing may be accounted for by the fact that the presence of 
carbon dioxide in the blood corpuscles increases the free- 
dom with which the haemoglobin parts with its oxygen, 
thus promoting oxygenation of the vital tissues. 

The beneficial effect of rebreathing carbon dioxide and 
oxygen when depression of the respiratory centre exists, 
has become so generally accepted that makers of oxygen 



CARBON DIOXIDE AND REBREATHING 305 

gas supply a mixture of oxygen and carbon dioxide (5 
per cent.) for therapeutic purposes. 

We regret that space permits of but a brief intro- 
duction into this most fascinating subject and refer the 
interested reader to the appended bibliography. 

In conclusion we would emphasize the fact that re- 
breathing is not dangerous to health as was formerly sup- 
posed, that in ordinary respiration we rebreath six-sevenths 
of our vital respiratory capacity, and that rebreathing into 
a bag is a matter of relative importance rather than of 
absolute difference. We would recall to mind the fact 
that carbon dioxide is distributed uniformly throughout 
the mass of blood and that carbon dioxide and oxygen exist 
in the blood independently of one another. We would 
impress the fact that carbon dioxide is not the cause of 
cyanosis, that it is only occasionally incidental to it, and 
that the color of the blood is entirely due to the amount 
of oxygen present. We would recall to mind the fact that 
a reduction of C0 2 gives rise to a condition known as 
acapnia, which may, if extreme, lead to apncea. On the 
other hand an increase of C0 2 known as hypercapnia fre- 
quently results in more or less dyspnoea. The open 
method is characterized by acapnia and apnoea ; the closed 
method by hypercapnia and dyspnoea. Hypercapnia may 
be more easily controlled than acapnia, is of distinct advan- 
tage in the control of the anaesthesia, and may often prove 
beneficial to the patient. We would draw attention to the 
fact that rebreathing is of distinct advantage where there 
exists respiratory depression from the use of morphine, 
and we feel that the closed method is the method of choice 
whenever the patient is critically ill. The advantage of the 
closed method, and the rebreathing which it implies, may 

20 



be explained by the fact that 
oxyhemoglobin dissociates more 
readily in the presence of abun- 
dant carbon dioxide. 

Experiment in Respira- 
tion. — In the course of some ex- 
periments in respiration bringing 
out the theories advanced by 
Yandell Henderson, an under- 
graduate student in the Univer- 
sity of California Medical School 
held his breath ten minutes. 

This was accomplished by 
having the student lie on a table, 
with a pneumograph^ belt at- 
tached about his thorax and com- 
municating with a kymograph. 

Slow, deep inspirations were 
taken for two minutes: this 
eliminated a good portion of the 
carbon dioxide from the blood. 
A breath of oxygen was then 
taken and the time marker 
started. The tracing is here 
shown. A slight relaxation of 
the respiratory muscles is indi- 
cated at two minutes. No desire 
to breathe was experienced until 
six minutes had elapsed. The 
belt having been placed over the 
diaphragm, the pulse rhythm was 
shown throughout. From this 



CARBON DIOXIDE AND REBREATHING 307 

time on, the conscious effort to hold the breath increased 
until an involuntary twitching of the abdominal muscles 
was quite apparent ; but no respiration took place. All the 
time the pulse was full and strong, the color good. No 
oxygen want appeared. 

At the expiration of ten minutes some vertigo occurred, 
and the impulse to breathe having become imperative, the 
first inspiration was taken — ten minutes and ten seconds 
having elapsed. No great hyperpncea, no weakness, no 
heart changes appeared. The student rose from the table 
and went about his class work (Fig. 124) . 






CHAPTER XVII 
EMERGENCY ANESTHESIA 

For the best results in the administration of an anaes- 
thetic suitable apparatus should be employed. Occasion- 
ally, however, we find ourselves without our familiar 
tools and are obliged to improvise others. If the 
signs of anaesthesia are thoroughly understood, we may 
often successfully surmount the difficulty confronting 
us. Improvised apparatus, however, instead of offering 
the easiest means of administration, usually, by virtue 
of their inefficiency, make the administration more difficult. 
In the long run the efficient method is the easiest and the 
most dependable. 

The hints which follow are intended to apply only 
when the exigencies of the occasion preclude the use of 
the proper apparatus. Their successful application will 
depend to a very large degree upon the mechanical clever- 
ness of the administrator. 

We will imagine ourselves stranded in an out-of-the- 
way place without our usual paraphernalia. 

When no Anesthetic Agents are at Hand. — 
When the usual anaesthetic agents are not at hand, the 
employment of morphine and scopolamine hypodermi- 
cally, in repeated doses will be found very valuable. Hyo- 
scine and scopolamine being considered identical, we will 
use these terms interchangeably. The dose of these drugs 
for an adult is morphine gr. J4> hyoscine gr. 1/100. At the 
end of an hour the dose may be repeated. The effect se- 
cured by two injections is often sufficient to enable one to 

308 



EMERGENCY ANAESTHESIA 309 

operate painlessly. Where after two doses the anaesthesia 
is not yet satisfactory, the dose may be repeated. The 
reflex pain which results from the surgical manipulation 
appears to neutralize to a large degree the depressing 
effects of these drugs. Atropine, hypodermically, in 
doses of 1/100 gr. and rebreathing applied by means of 
towels, will help to control respiratory depression. The 
method is one of necessity not of choice. 

Freezing the part (page 249), pressure on nerve 
trunks (page 250), and pressure producing ischaemia of 
the part (page 251), may be employed in an emergency. 

Where novocaine and cocaine are to be had, the results 
will be limited only by the skill of the operator. Cocaine 
is more plentiful than novocaine and it is only because of 
this reason that its use is suggested. It is about seven 
times more dangerous and should never be used in a 
maximum dosage of more than one grain. 

Where Ether., Chloroform and Ethyl Chloride 
are Available. — Any unopened container with ether, 
chloroform or ethyl chloride marked for ancesthesia may 
be considered safe. 

Ether which has been exposed to the air for some time 
and which may be suspected of being unsafe should be 
tested as follows, before being administered. 

1. Upon evaporation it should leave no residue. 

2. Allowed to evaporate spontaneously there should 
be no perceptible, foreign odor present when the last 
traces have disappeared. 

3. There should be no change in color on the addition 
of KOH (color indicating the presence of an aldehyde). 

4. Ether should not affect blue litmus paper even after 
twenty-four hours' contact. (Indicating absence of acetic 
acid.) 



310 ANESTHESIA 

5. There should not be an undue amount of water or 
alcohol present. (If 20 c.c. of ether and 20 c.c. of water, 
previously saturated with ether, be shaken together the 
ether layer on separation should not measure less than 
19.5 c.c.). 

Chloroform which has been exposed to air and light 
should be tested as follows, before being administered: 

1. It should possess a specific gravity of not more than 
1.495 and not less than 1.490. (Lower specific gravity 
indicates an excess of alcohol.) 

2. It should be perfectly transparent and colorless. 

3. It should be absolutely neutral to test paper. 

4. It should possess an agreeable bland and non-irritat- 
ing odor. 

5. When allowed to evaporate spontaneously it should 
leave no residue either of water or any substance possess- 
ing a strong smell. 

6. When shaken with concentrated sulphuric acid no 
brownish coloration should result. It should form no pre- 
cipitate with a solution of silver nitrate. 

7. It should not acquire a brown color when heated to 
the boiling point with caustic potash. 

Ethyl chloride is not likely to suffer from exposure to 
air because of its extremely low boiling point (its very 
great tendency to vaporize). It should be neutral in 
reaction and leave no residue when vaporized. 

The Administration or Ether by an Improvised 
Open Method. — An ordinary, small, hand towel is folded 
around the nose and mouth, leaving the latter free. Cheese- 
cloth in eight or ten thicknesses, or one thickness of a bath 
towel, is then laid over the top of this. The drop bottle is 
immediately improvised by puncturing the centre of the 
ether can cap with a single pin hole. The rate of flow of 



EMERGENCY ANAESTHESIA 311 

the ether from this hole is regulated by the tip of the index 
finger. 

If the head and the face are covered during the course 
of an operation on the face, ether may be sprayed directly 
on that part of the sterile sheet over the mouth without 
disturbing the asepsis of the field of operation. A patient 
suffering an operation under local anaesthesia recently was 
thus anaesthetized by the author. 

When ether is given in this improvised fashion, we 
must bear in mind the possibility and danger of liquid 
ether being allowed to find its way into the mouth of the 
patient. 

The Administration or Ether by an Improvised 
Semi-Open Method. — The use of the towel cone is quite 
common where the need of a semi-open or closed method 
is felt but undeveloped. We cannot speak of this method 
as a closed one because the space devoted to rebreathing 
is so small as to necessitate the entrance of atmospheric 
air about the edges of the mask. Such a mask as we are 
about to describe acts quite efficiently as an open and 
semi-open method. 

The material necessary for its construction consists of 
a towel, a newspaper, gauze, cheesecloth or a few strips 
of soft, woolen rags. 

The mask is made as follows: Five sheets of ordinary 
newspaper are opened wide and laid on a table or on the 
floor. These five sheets are then folded lengthwise twice. 
There is now a strip of newspaper twenty sheets thick 
about six inches wide, and as long as the newspaper is 
when opened wide. This strip is now laid on an ordinary 
hand towel (1 yd. x y 2 yd.) lengthwise, so that the paper 
comes in contact with the long, free edge of the towel. If 
the strip of paper projects beyond the towel, it may be 



312 ANAESTHESIA 

torn off. The paper may be an inch or two short without 
effecting the result. A towel three feet long and one and 
one-half feet wide will now be covered by paper on one- 
third of its area. The paper and towel are now grasped 
at one end and a fold of about seven inches is made (Fig. 
125 a and b) . The towel is outside and the paper inside. 
The folding is continued until the entire length of the 
towel and the paper is included. The result is a tube of 
paper and towel (Fig. 125 c). The hand is now thrust 
through the tube thus formed (Fig. 125 d), and grasps 
the free end of the towel pulling it through, so as to form 
a lining for the tube (Fig. 125 e) . The roll (Fig. 125 
/) is now held between the knees and the free end is 
drawn snug. The surplus is then turned down over the 
top of the roll like a collar (Fig. 125 g). It will fit 
snugly, needs no sewing and a single pin will serve to 
hold down the one loose corner. 

Sewed cones are a nuisance to make, and because of 
this, one is sometimes tempted to use them twice — a most 
unpardonable practice. 

A strip of gauze is now poked gently into the top of 
the cone, care being taken that it does not come in contact 
with the face. (When in doubt the cone should be in- 
spected by turning it upside down.) Ether may now be 
dropped or sprayed upon the gauze or cheesecloth. When 
it is desirable to increase the concentration of the vapor, 
the flat of the hand may be laid partly or wholly over the 
vent. At frequent intervals the gauze should be taken 
out and shaken, as it soon becomes saturated with moist- 
ure from the expirations. This inhaler is simple, relia- 
ble and as efficient as any semi-open method known to us. 
Incidentally we would mention the towel cone sealed 




- 


f ' 






^ 




ba 


H 


4 


O 




t*3 


3- 


t- 


3i 




N 




*J 





l: 




i 



314 ANAESTHESIA 

at one end, only tD condemn it as asphyxial and inefficient. 

The Use of Chloroform in Emergency Anesthe- 
sia. — The use of chloroform in emergency anaesthesia 
should be strictly limited to the C. E. mixture (see page 
194). It should never be employed where there is a limi- 
tation of air. It should not be used where there is a gas 
light or other flame. Unless a proper mask is available, 
the face should be anointed with vaseline to prevent burn- 
ing of the skin. The use of chloroform in emergency 
anaesthesia should be limited to the period of induction. 
The physiology of chloroform anaesthesia (page 185) 
should be understood, and the causes of death (page 195) 
should be thoughtfully anticipated. 

Small quantities of chloroform on a gauze sponge, 
held before the patient by means of a sterile sponge holder, 
are sometimes used for operations about the face. 

The Use of Ethyl Chloride in Emergency Anaes- 
thesia. — The use of ethyl chloride as an emergency anaes- 
thetic is suggested chiefly as a substitute for nitrous oxide. 
We would emphasize the necessity of great care in its use 
and recall to the reader's mind the tendency of the patient 
to collapse, following its use. It has its place, neverthe- 
less, and if cautiously used, will be found quite serviceable. 

Intrapharyngeal Anesthesia by Improvised 
Methods. — The patient is anaesthetized by the improvised 
towel cone. When anaesthesia has been well induced, a 
catheter or small rectal tube is slipped into one of the 
nostrils. (If two catheters are available, having a " Y ' 
tube connection, so much the better.) The end of the 
1 catheter is now fitted into a piece of rubber tubing, this, in 
turn, over the top of the ether can; a few drams of ether 
are then poured into the can. The vapor thus formed is 



EMERGENCY ANAESTHESIA 



315 



respired by the patient. Great care must be taken to pre- 
vent liquid ether from finding its way into the catheter. 
This may be prevented by holding the can upright so that 
no liquid ether will run out. 

With this method we depend upon the amount of suc- 
tion through the tube brought about by the respirations 




Fig. 126. — Tin can method far nirta pharyngeal anaesthesia. 



of the patient. This varies with the freedom of the respira- 
tion. Morphine and atrophine should always be used to 
avoid obstruction by salivation. 

Intratracheal Anaesthesia by Improved Appara- 
tus. — Intratracheal anaesthesia may be satisfactorily ad- 
ministered by employing a technic similar to that described 



316 



ANAESTHESIA 



for the emergency intrapharyngeal method. When this 
method is employed, we introduce a tube directly into the 
trachea, attaching the distal end to a tube which connects 
it to a funnel as described above. This method is much 



F * 1 




£& / 7 ill 


1 ' 


\0rjb 



Fig. 127. 



-Funnel with tube for intratracheal anaesthesia. 
American Journal of Surgery.) 



(Courtesy- 



mOre efficient than the intrapharyngeal method, because 
a much larger volume of air passes through the tube. An 
apparatus similar to the one shown in Fig. 127 has been 
repeatedly used with much success. 

The danger of such a method in inexperienced hands is 



EMERGENCY ANAESTHESIA 317 

much greater than that described on page 159, but its 
usefulness where indicated, in the absence of the usual 
apparatus, can hardly be denied. By such a method it is 
impossible to obtain positive intrapulmonary pressure. 

Accessories to Emergency Anaesthesia. — A mouth 
wedge, necessary when masseteric spasm and cyanosis 
occur, may easily be improvised by whittling a piece of 
hard wood in the form shown in Fig. 13. 

A breathing tube, acting in the capacity of the Connell 
throat tube, Fig. 14, may readily be made from a five-inch 
piece of rectal tube or other stout tubing having a diameter 
of at least half an inch. A safety pin should always be 
fastened across the outer end. 

If, in the course of an abdominal operation, the pulse 
becomes small and rapid, indicating hemorrhage and the 
need of a saline injection, the quickest and most convenient 
way of administering this is to pour hot saline directly into 
the abdominal cavity. While this is being done, an ordi- 
nary fountain syringe should be filled with warm saline, 
and a hypodermoclysis needle attached to the tubing lead- 
ing therefrom should be thrust deep into the loose tissue 
under one of the breasts. The height of the rubber bag 
determines the rate of the flow. It may be started at three 
feet above the patient and raised if the flow is not suffi- 
ciently rapid. Hypodermoclysis is an exceedingly satisfac- 
tory means of introducing saline solution into the general 
circulation. The effects are not so rapid and it may 
safely be started at an earlier time than can an intravenous 
injection. The greatest advantage, however, lies in the 
fact that it does not delay the course of the operation by 
requiring the attention of the surgeon or his assistant. 
All the necessary details may be cared for by the nurse, 
working under the direction of the anaesthetist. 



CHAPTER XVIII 
THE ANESTHETIST'S RECORDS 

Those who administer anaesthetics sooner or later find 
it essential to preserve a fairly comprehensive record of 
each case. This becomes necessary not alone from a scien- 
tific point of view, but also for self -protection. 

It is frequently inconvenient to gather personal data at 
the time of the operation. To avoid this embarrassment a 
record card and a self-addressed, stamped envelope may be 



NAME 


DATE OF OPERATIONS NO. 


AGE SEX ADDRESS 


NAME AND ADDRESS OF NURSE 


OPERATIONS 


SURGEON 


ASSISTANTS 


UNCONSCIOUSNESS AFTER OPERATION 


/ /VW<^1 PREVIOUSLY ANABSTHETIZEO / 'Ht.Q 


condition or eves after operation 


&1<. „CHAR OF INDUCTION ^UaJ- OyigrdM^G. 


f teeth / HJlAr cxAirtfsfs. rigidity. 


JA£JtT7TFioN. MjlCOTOV VOMITING BEfdrfl, OUJMrfQ. AFTER 


ANAES. SUCCESS S CH^ 


p dii a erK 


REMARKS 



bill sent: paioj. 

Fig. 128. — Front of anaesthesia record card. 



left with the nurse, who is usually glad to secure the desired 
information. The accompanying figures illustrate such a 
card. 

The front of the card (Fig. 128) requires but little 
comment. 

Char, of Induction. — Excitement absent, moderate, 
marked. 

Ances. Success. — S., Point of view of the surgeon; P., 
of patient; A., of Anaesthetist. 

318 



THE ANAESTHETIST'S RECORDS 



319 



Heads for data which are absent should be crossed out. 
On the reverse of the card (Fig. 129) attention may be 
directed to the following points : 



System Anaesthesia 






^K*-*-v 






Apparatus Csfctf 












",o+f 




»3 wcicisi 


r 






ETHER 




i 6 
6 x, 


i *v 




r»i. 


£}U&f(6?ORM 




6 


tf 




k ? 


M. & A. 


kU 


cU, 


/on" „ 


*>*. 




JJ£*<fEN 












Jtfmtilants 












Respiration 




i ° { 


tti 






C REFLEX 




U. 1 


[JA 






PUPIL 




ct c c 


c c^ cl 








180 

170 

160 

160 

140 

130 

120 

110 

100 

90 

60 

TO 

60 


BEFORE 

ANAESTHESIA 


ANAESTHESIA 

BEGUN 


1ST HR. 
20 40 60 


2ND HR. 
20 40 60 


3RD HR. 
20 40 60 


CONSCIOUSNESS 

RETURNED 




A.M. 


A.M. 




















P.M. 


< 


























35 


























2* 


























S2 






















































































• 














a 






, 












































/.** 




• 


/OJ/t 
















































TOTAL TIME OPERATION /../<3 ANAESTHESIA 2. -*0 


ANAESTHESIA BEFORE OPERATION • / <* 



Fig. 129. — Reverse of anaesthesia record card. 



System of Ancesthesia. — Open, closed, pharyngeal, in- 
tratracheal, intravenous, rectal, etc. 
M. <§ A. — Morphine and atropine. 



J 



320 ANAESTHESIA 

Respiration. — Free, obstructed. 

C. Reflex. — Sharp, dull, absent. 

Pupil. — Normal, contracted, dilated. 

Most records are squared off for five-minute pulse- 
readings. To save space twenty-minute divisions are here 
used. Five-minute readings may be shown by a dot one- 
fourth way across the space.* 

* Reprinted modified from Journal of the American Medical Association. 



CHAPTER XIX 

ASPIRATORS 

The use of aspirators particularly for nose and throat 
work, is of interest to the anaesthetist, as their employ- 
ment aids materially in controlling the freedom of the 
respiration. 

Four types of aspirators may be recognized : 

1. Where the suction is produced by a foot pump. 

2. Where the suction is produced by water power. 

3. Where the suction is produced by electricity. 

4. Where the suction is produced by steam power. 
The foot pump method is the most simple but the least 

efficient of the four methods. A foot pump sucker suita- 
ble for throat and abdominal work is shown in Fig. 130. 

Aspiration by water power is quite popular. The suc- 
tion which results is constant and quite efficient. When 
in use the apparatus is attached to any convenient water 
faucet. The amount of suction produced depends upon 
the head of water at command. If the faucet is located 
at the top of the building some difficulty may be experi- 
enced in securing sufficient water power to produce the 
desired result. The essential features of the apparatus 
are shown in Fig. 131. 

Aspiration by electricity is often used where ether 
vapor is being delivered for throat work. In this case the 
suction produced by the blower which provides air to form 
the ether vapor, is employed. The disadvantage of this 
particular arrangement lies in the fact that the air used 
to vaporize the ether is taken (by suction) from the de- 

21 321 



322 



ANESTHESIA 




Fig. 130. — Foot aspirator, Roosevelt Hospital. 



ASPIRATORS 



oxygenated and contaminated field of operation. The 
noise of the motor is often very annoying and a satisfac- 

A 




Fig. 131. — Water aspirator. 



tory electrical supply must be near at hand. It has 
the advantage, however, of being very convenient. An 
example of such an apparatus is shown in Fig. 132. 



324 



ANESTHESIA 



Aspiration by steam. This type of aspiration is not 
only of value in nose and throat work, but plays even a 
larger part in removing fluid from the abdomen and else- 




Fig. 132. — Electrical aspirator. 



where. The utilizing of steam for suction purposes is 
brought about by the employment of what is known as an 
ejector. This ejector, a cross section of which is shown 




Fig. 133. — Ejector for steam aspirator. 



in Fig. 133, may be purchased at any steam fitting 
establishment. 

The steam in passing from A through F into G and 
finally into the discharge pipe E produces a partial vacuum 



ASPIRATORS 



325 



in the chamber enclosing F and G 3 which, being connected 
to the suction tubing marked " supply," performs the 
intended work. 

The steam supply pipe A may be one which is tapped 
at any convenient place in the sterilizing room or else- 




Fig. 134. — The steam pump aspirator complete with aspirating tongue depressor, 
Fordham Hospital. 

where. The discharge pipe E may be led into a pail of 
water or be discharged at some point in the basement or 
out of doors. 

Fig. 134 is a view of the entire apparatus in question — 
ejector, tubing, receiving bottle (for aspirated material) 
and aspirating tongue depressor. 



326 



ANESTHESIA 



The bottle which receives the discharge should have a 
capacity of about 2000 c.c. The tubing between the ejec- 
tor and the bottle may be of pressure hose or, better still, 
flexible steel gas tubing, as shown in the illustration. This 




Fig. 135. — A, Aspirating tongue depressor; B, tongue depressor. 



tubing should be at least fourteen to eighteen feet long. 
If a greater length is required it is more satisfactory to 
replace part of this by permanent piping from the ejector. 
The distal end of this tube is soldered to a length of brass 
tube perforating the cork in the bottle. This cork must 



ASPIRATORS 327 

be considerably larger than the mouth of the bottle, else it 
will be sucked in by the powerful negative pressure. 

The tubing from the bottle to the aspirating tongue 
depressor is of heavy non-collapsible rubber, capable of 
repeated sterilization. 

Whatever may be the source of the suction produced, 
foot power, water, electrical or steam, the actual removal 
of the fluid is accomplished by variously shaped, per- 
forated, metal tubes. A common type is shown accom- 
panying the electrical aspirator. A tongue depressor 
which aspirates, however, is the ideal. Fig. 1S5A is the 
aspirator employed by the author. It is made to corre- 
spond as nearly as possible to the shape and size of a popu- 
lar tongue depressor, shown in Fig. 1352?, and when in use 
it does away with the necessity of employing an additional 
instrument, as it acts in the capacity of an efficient tongue 
depressor and aspirator at the same time. 



CHAPTER XX 
THE POINT OF VIEW OF THE PATIENT 

Medicine for many of us is the centre about which 
the world revolves. We see life in its embryonic dawn. 
We follow it most closely in its morbidity through adoles- 
cence, maturity and decline, until at last the spontaneous 
metabolism is at an end. Lead on by experimental curi- 
osity into the nature of things, we do not leave man here 
but dissect him with scalpel and microscope to the limit of 
present day instruments. By electrical and chemical 
stimuli we effect a parody on life; we make dead muscle 
move again, and look therein for the secret of life. 

From within the circle drawn by medicine we limit our 
speculations as to the great truths. We build our theology 
out of coarse stuff and wonder why the edifice is so unsatis- 
factory. We ignore the more delicate tools of logic and 
philosophy, which are equally as truthful and more 
penetrating. 

The medical man has a tendency to relegate the intel- 
lectual life to the obscure environment of psychiatry. The 
intellectual life to him, broadly speaking, is but the reac- 
tion to environment and of comparatively small account 
at best. The distinction which he draws in his own mind 
between a man and a monkey is not very acute. While 
not always openly acknowledged, many present day medi- 
cal men serve the cult of materialism. With such a more 
or less well defined materialism they approach their 
patients. Their patients are the world. 

The average layman has little or none of the physi- 

328 



POINT OF VIEW 01 PATIENT 329 

cian's detailed knowledge and interest in histology and 
pathology. He has occupied his life in listening to the 
call of the " ego," that intangible, intellectual entity which 
is self. Such patients view medicine, and in viewing medi- 
cine, judge us from a point of view, which it would be well 
for many of us to appreciate. As a science cannot be 
broadly judged from its own plane but must needs be 
seen from without, so can we best serve our patients by 
viewing our profession from without. 

The wealthy, by their influence, social and financial, 
obtain through the very atmosphere with which they sur- 
round themselves, a certain consideration, irrespective of 
our habitual personal mannerisms. The deference paid 
these by the materialistic man, by him who cannot under- 
stand the spiritual element, is a deference to the peculiar 
qualities which the former possess, their keen mentality, 
their natural refinement and their wealth, rather than to 
their deeper humanity. His sympathy finds its reward ifi 
immediate common interests. On this ground the materi- 
alist is fairly well remunerated, but what stimulus has he 
for a charity for which he can see no reward? 

It is the poor who send up this cry; the poor in the 
great hospitals and dispensaries. Those from whom we 
feel that we tolerate much and who are perpetually in need 
of help. They cannot reward us by money, they cannot, 
and by nature often will not, reward us by sparkling wit 
or by dull thanks. If we would be compensated we must 
see an image of the Almighty in their presence. We must 
feel the unspoken thanks which illiteracy cannot utter. 
We must look beyond the colorless environment of the 
hospital ward and see the situation from their point of 
view. 



330 ANAESTHESIA 

Let us pass from the narrow confines of their station 
in life and go with them to the great hospital with its 
subtle wonders, a universe in itself. Here the house sur- 
geon wields a monarch's sway. By his orders we fast or 
eat, we are allowed to go about or we are obliged to stay 
abed all the day. He controls the nurses, who have 
power enough, goodness knows, when he is absent. 

As for the visiting surgeon, he is a sort of a deity. He 
rules even the house surgeon. His will is law and his 
every remark is treasured up to be produced at intervals 
for the benefit of a coterie of friends. Imagine that celes- 
tial body, as he moves about in his orbit stopping before 
one of these people. Imagine the pain inflicted by a curt 
remark, by a rough manipulation or by a misapplied pun, 
forgotten in the saying perhaps by him, but treasured 
through the long, uneventful day by the patient; imagine 
the unsatisfied thirst for just a little information when 
the sudden declaration is made: " We will operate to-mor- 
row at three." 

To-morrow dawns at last, but it is a long wait before 
afternoon. During the wait one has nothing to eat and 
is nervous with apprehension. Three o'clock finally 
arrives but the minutes pass by in suspense until it is 
perhaps nearly four; then quite accidentally a nurse may 
think to inform the patient that the doctor called a few 
hours ago to say that he had decided to postpone the opera- 
tion until the following day. The operating staff had 
been informed of course, Jbut no one had remembered to 
tell the patient. Then follows the sudden relapse when 
the tension is released. The suspense is only prolonged, 
however, for the next day is to come. But now the possi- 
bility of a second delay enters in and nothing is sure until 



POINT OF VIEW OF PATIENT 331 

the stretcher is brought and the patient is conveyed to the 
operating room. 

The anaesthetist is unconcerned. From his point of 
view the patient entered into his presence from apparent 
oblivion and will leave him in real oblivion. Perhaps it is 
a little woman, who trembles now and then; whose teeth 
chatter and whose eyes persist in filling up in spite of her- 
self. If the anaesthetist would only see her point of view, 
he could not refuse to comfort her; but instead of this, in 
an impersonal, colorless voice he sharply remarks " Here, 
stop that nonsense. We can't have any of this fuss." If 
he only knew how impossible it was for the patient to 
control herself and how gladly she would stop " that non- 
sense," if she could. In an equally impersonal manner 
she is told that no one is going to hurt her, or, what is 
worse, the anaesthetist may calmly putter for an intermina- 
ble time in his preparations and when about to start is 
told to wait, as the case under operation is not far enough 
advanced to start the next one. Then follows another 
delay of perhaps half an hour in the close etherizing room 
with every minute threatening a climax. Finally the 
order is given to start the anaesthetic. Speed is essential, 
hence concentrated ether, hence cough, suffocation, stran- 
gling and a sense of sinking into utter nothingness. An 
effort to free one's self, and one's hands are pinned down 
on one's breast, which pressure adds to the distress. Long 
before consciousness is lost someone cries out " Soak it to 
her, soak it to her." These last words echoing and re- 
echoing down the long vista leading out of consciousness. 

This is not intentional cruelty, it is the result of high 
pressure, of system gone mad and most of all of the lack of 
appreciation of the patient's point of view. 



332 ANAESTHESIA 

But the reduction of the ego to a greater or less amount 
of Nissel's granules does not elevate one's views, it but con- 
centrates them. The motive is analogous to that of pure 
conservation of energy in a machine. It does not attract 
all. It appeals mostly to the pathologist, to the histolo- 
gist or to the biologist and its consideration proceeds not 
from a warm sympathy but from good policy. 

There are possibilities in men outside the limits of ions 
and their uncounted subdivisions. There are qualities 
inherent in that hidden power, which is born in the union 
of sperm and ovum, predominating and directing cell divi- 
sion, assigning each to its delicate community task. It is 
this intelligence which permits the organism to adopt itself 
to its peculiar circumstances with the marvelous aptitude 
which we know so well. It controls a system of repair 
and defense so complex that we can but theorize as to the 
mode of its action. As we direct our attention to the 
physiology and the organic chemistry of the cell, we "lose 
sight of the larger, more amazing community life of the 
countless groups of differentiated cells, each working along 
independent lines for the common good. These groups, 
if not guided in their ensemble by a central authority, 
could never adapt themselves to the vicissitudes of 
environment. 

One need not follow the isms of the faddists to be up 
to date. Truth is not a matter of time or place, it is 
unchangeable. The acknowledgment of the existence of 
the supernatural in the soul of man is not an evidence of 
reversion in type. It is but the result of the acceptance 
and of the intelligent correlation of a host of facts which 
we see about us. 

Admitting the presence of a soul, and as the logical 



POINT OF VIEW OF PATIENT 333 

sequence the attributes and adornments of the soul, 
may we not awaken and develop the loveliest of these, 
charity, seeing in man, however poor and illiterate, the 
seal of divinity. Courtesy is honored when found in such 
company. 

A man who can see the divine, has an incentive which 
is impossible in the case of the mere microscopist. He can 
understand that charity is its own reward and as a con- 
sequence he offers it whenever possible. 

We can therefore, in adopting the patient's point of 
view, eliminate much pain and distress. The acceptance 
of such a course involves no expense. A moment of 
thoughtfulness is all that is required. A word, a smile 
or a sympathetic glance will do much to lighten anxiety 
and pain. Morning operations when possible; avoidance 
of postponements ; a morphine precedence ; unfailing cour- 
tesy and consideration — all these may seem trifles, but in 
reality are marks of human kindness. 

In such a measure as a man spends his efforts in doing 
good to others, in just such measures will he find peace 
and contentment within himself.* 

* If the reader cares to pursue the point of view of the patient, he 
is referred to the author's book, " The Patient's Viewpoint." Bruce Pub- 
lishing Company, Milwaukee, Wis. 



CHAPTER XXI 

THE SELECTION OF THE ANESTHETIC AND 
THE METHOD OF ADMINISTRATION 

The proper selection of the anaesthetic agent and its 
method of administration implies an expert knowledge 
and intimate acquaintance with the entire field of anaes- 
thesia. To know when to use the correct anaesthetic agent 
is secondary to a knowledge of how to use it. While chlo- 
roform is indicated, for example, in the case of Ludwig's 
angina, to make use of it without an intimate acquaintance 
with its behavior would be to court more danger than to 
use ether with skill bom of constant usage. The element 
of skill would here counterbalance the specific action of the 
drug. On the other hand, the routine use of a solitary 
anaesthetic agent or sequence is not an excuse to exclude all 
others. The expert anaesthetist must become acquainted 
with the various anaesthetic agents which he may be called 
upon to use. As an artist becomes skilful in mixing his 
colors, so must the anaesthetist become skilful in arranging 
his anaesthetic sequences. He must combine the require- 
ments of the individual patient, the operative procedure, 
and the peculiarities of the surgeon, so that the end result 
will be a safe, rapid induction, a maintenance entirely un- 
der control, and a speedy, uneventful recovery. 

In recent years there appears to have been more prog- 
ress made in the perfecting of methods of administration 
than in the discovery of agents which are safer and more 
efficient. The use of ether was formerly attended with so 

334 



SELECTION OF THE ANESTHETIC 335 

much embarrassment in certain types of cases that it was 
necessary to abondon its use and to substitute for it chlo- 
roform or the C E mixture. Conspicuous among those cases 
which bore ether badly were the short, thick-necked alco- 
holic or athletic individuals. These patients were prone to 
develop a sharp period of excitement accompanied by in- 
tense masseteric spasm and cyanosis. As the respiration 
was obstructed, it was difficult if not impossible to intro- 
duce enough ether into the circulation to complete induc- 
tion. Even though teeth were forcibly separated by a gag, 
the respiration remained shallow and unable to carry suf- 
ficient ether into the lungs of the patient to control him. 
The only alternative was to make use of an anaesthetic po- 
tent enough in small doses to bring about control. This 
anaesthetic was chloroform. The advent of the metal 
pharyngeal breathing tube by overcoming respiratory ob- 
struction and giving free access to large volumes of respired 
vapor, has increased the efficiency of ether anaesthesia to 
such an extent that we do not find it necessary to use chlo- 
roform in this type of case. Chloroform was formerly used 
as a routine anaesthetic in cases of glands of the neck, goitre 
operations, intracranial operations, operations for excision 
of the tongue or maxillary bones. We no longer think of 
using chloroform in these cases, but use ether by the method 
of intrapharyngeal insufflation or inhalation, preceded by 
preliminary morphine and atropine medication. The 
safety and the efficiency of the anaesthetic has increased 
through our knowledge of the proper method of administra- 
tion. And so it has come to pass that the selection of the 
method of administration is of as much importance as the 
selection of the anaesthetic agent. 

The selection of the anaesthetic then must be determined 



336 ANAESTHESIA 

along the following lines: We must choose the safest, 
most efficient and agreeable anaesthetic which experi- 
ence points out as being best adapted to the patient under 
consideration. 

Our available anaesthetic agents may be practically lim- 
ited to ether, chloroform, nitrous oxide, nitrous oxide and 
oxygen, ethyl chloride and various mixtures of these 
agents, as, for example, the C E mixture, anaesthol, etc. 

Nitrous oxide and oxygen is the safest anaesthetic. 

Chloroform is the most efficient. 

Ethyl chloride is now being used quite freely for mili- 
tary surgery, particularly in France, where it is extoled 
for its pleasant odor and its evanescent, non-toxic effects. 1 

But for all-round use, where a complete general anaes- 
thesia is desirable, ether remains pre-eminent. It is safe, 
it is efficient, and if preceded by sufficient nitrous oxide to 
destroy consciousness it becomes entirely acceptable. 

The safety of the anaesthetic is naturally our greatest 
concern, and from the point of view of the anaesthetic alone 
should be paramount. But one must not forget to consider 
the object of the anaesthesia. It is necessary to bear con- 
stantly in mind the fact that the patient is anaesthetized 
in order that the surgeon may operate with the greatest 
possible ease. The control of pain is self-evident, but the 
control of inconvenient movement and muscular rigidity is 
often ill considered. Instead of delivering a safe, efficient 
and agreeable anaesthetic, the anaesthetist often provides an 
anaesthetic which is agreeable, safe and efficient. The sur- 
gical procedure is hampered in order that the anaesthetic 
may be pleasanter. When we consider the safety of the 
anaesthetic we must consider it from the surgical as well as 

1 M. Boureau, La Presse Medicale, 21 Mai., 1917. 



SELECTION OF THE ANESTHETIC 337 

from the anaesthetic point of view, for the anaesthetic is but 
a means to an end. If the end for which the anaesthetic 
is being delivered is jeopardized, if the patient's life is en- 
dangered through hampered surgery, then the anaesthetic 
which was safe enough in itself becomes a source of dan- 
ger to the patient. For example, suppose the safest of all 
anaesthetic agents, nitrous oxide and oxygen, be used alone 
in an exploratory laparotomy. In the course of the explor- 
ation gall-stones are found. The lack of relaxation re- 
stricts the field of operation. The liver cannot be deliv- 
ered, the operator must work in a deep cavity, the hazard 
of removal and ligation of the stump, cystic duct and ves- 
sels is increased. The lack of proper relaxation makes 
closure difficult and perhaps incomplete, predisposing to 
ventral hernia. Under these circumstances the safest an- 
aesthetic per se becomes a dangerous one through its indi- 
rect effect upon the operation. 

It is for this reason that safety must sometimes give way 
to efficiency in order that the end result may not suffer. 

The condition described above is common enough. The 
explanation of the situation lies in the fact that there are 
more amateur surgeons than experts. A man who is not 
familiar with the proper relaxation needed for intra-ab- 
dominal work cannot find fault when it is absent. This 
occasional operator is apt to mislead the occasional an- 
aesthetist into thinking that the anaesthesia was ideal and 
overlook any possible difficulty which may have arisen 
when he finds his patient conscious before she leaves the 
operating room. 

The agreeableness of the anaesthetic, its acceptability, is 
of very considerable importance, but it should not be 
allowed to supersede safety and efficiency. 



338 ANAESTHESIA 

The anaesthetic is naturally selected according to the 
age and the sex of the patient ; the nature and the site of 
the operation; specific pathological conditions influencing 
the course of the anaesthesia. 

The Age and the Sex of the Patient 

The extremes of age do not appear to contra-indicate 
the administration of a general anaesthetic. The author has 
anaesthetized infants of a few hours as well as patients over 
ninety years of age. As a matter of fact, the infant in 
utero is usually anaesthetized during the course of a pro- 
longed obstetrical operation and recovers from his anaes- 
thesia after birth. On the other hand, anaesthetics have 
been successfully administered to centenarians. 

One of the most satisfactory methods of anaesthetiz- 
ing tiny infants is to induce anaesthesia by the open drop 
method. This method is used until the baby stops crying 
and the respirations assume a more or less regular rhythm. 
Ether is then maintained by oral inhalation as described 
on page 144. This method of delivering to the little patient 
minute quantities of concentrated ether vapor, which is 
allowed to mix with the atmospheric air under the mask 
before it is inhaled, yields the most delicate control with 
which we are familiar. 

Children up to the age of seven may be induced and 
maintained by these methods. 

Chloroform, ethyl chloride and the C E mixture may 
be used to induce infants and small children, but we have 
found ether safe, as efficient and quite acceptable, and are 
inclined to recommend it as a routine at this age. 

Children from seven to fifteen or eighteen years of age, 
if normally developed and in good health, are usually dif- 



SELECTION OF THE ANAESTHETIC 339 

ficult subjects to induce smoothly and to maintain evenly. 
They are often the victims of nasal and pharyngeal obstruc- 
tion from enlarged tonsil and adenoid growths, and are 
prone to secrete large quantities of mucus which serves to 
increase the obstruction. It is thought that children at the 
age of puberty are unusually difficult subjects because of 
the peculiar condition* of their nervous system. The age 
at which nitrous oxide and oxygen may first be used varies 
from five years to eight or ten. The limit depends more 
upon the physique of the patient than upon the age. Thus 
one might safely use nitrous oxide alone or nitrous oxide 
and oxygen to a large, well-developed child of five, where 
it would be unwise to do so in a poorly develped, anaemic 
youngster of eight or ten. The reason for this is that jac- 
titation develops very early in small children and the tidal 
volume is so small that it does not reach back into the 
bag of the closed apparatus which one must of neces- 
sity use. As a rule, it is not practical to maintain 
anaesthesia in children under ten by a closed method, 
hence either an open or a semi-open method is used. While 
ether is the routine anaesthetic for induction and mainten- 
ance, ethyl chloride by the open drop method or the C E 
mixture will yield a smooth and a rapid induction. 

When the respiratory organs become sufficiently 
developed to insure a tidal volume of at least 300 or 400 c.c. 
for each respiration the closed method may be used 
throughout the anaesthesia. This development usually ap- 
pears between the twelfth and fifteenth year, depending 
upon personal characteristics. 

Men with unshaven faces or with beards usually give 
trouble during gas induction unless cotton is placed be- 
tween the face cushion and the skin. The simplest method 



340 ANAESTHESIA 

to apply this cotton is to cut a square of sheet absorbent 
cotton as big as the face and half an inch thick. An open- 
ing is made in the centre of this sheet large enough for the 
nose and the mouth. The mask is then placed over all. 
This simple procedure will completely change the charac- 
ter of the induction and incidentally serve to absorb mu- 
cus and saliva. It may be discarded when induction is 
complete. 

Ordinarily a patient with a good physique will give more 
trouble than a patient who is shocked or septic. The nor- 
mal healthy individual is more sensitive to the stimulating 
effects of the anaesthetic than is the individual who has 
been wearied by pain, lack of sleep and sepsis, and con- 
sequently is prone to a protracted period of excitement 
and rigidity. From the point of view of the anaesthetist 
the sick patient is easy to control, but requires closer atten- 
tion than does the man with a normal physique. Prelim- 
inary medication by morphine and atropine often produces 
artificially the low grade irritability which is normally 
present in exhaustion. The normal vigorous individual re- 
quires speed, full dosage with a firm positive control; the 
sick man, on the other hand, requires deliberate care, a mini- 
mum dosage, with a delicate, constantly varying control. 
The sick man offers the best opportunities for refinements 
in anaesthesia and as a matter of fact they are his due. 

Elderly men are often surprisingly difficult to induce. 
They often mask, under sunken cheek and toothless jaws, 
intemperance seasoned by long years of indulgence. Their 
very existence is often proof of their vitality. But while 
induction may be difficult in these cases, maintenance is 
frequently the contrary. Age here quickly shows its ef- 
fects and we will often be surprised to find our patient slip- 



SELECTION OF THE ANAESTHETIC 341 

ping into a profound and even dangerous anaesthetic 
sleep. Hence it is well to bear in mind that in childhood 
and in second childhood maintenance must be carried on 
with the greatest care. Gas oxygen anaesthesia with 
enough ether for relaxation is well borne by the aged. This 
anaesthetic is especially adapted for maintaining anaes- 
thesia in any but intra-abdominal manipulations. We have 
found that this combination works so well that we have no 
occasion to use chloroform, although this agent is indicated 
in this class of cases. Nitrous oxide should not be used 
alone, however, owing to the danger of increased blood- 
pressure, resulting in the rupture of an atheromatous ar- 
tery. The employment of oxygen entirely obviates this 
difficulty. 

Women are usually easier to anaesthetize than men. 
The difference appears to lie in the physique, however, as 
one frequently encounters a woman of a masculine type 
who will give rise to considerable difficulty. 

Menstruation being usually concomitant with a tem- 
porarily altered vascular and nervous system argues for 
the postponement of the anaesthetic. Nose and throat men 
will not operate at this time because of the liability to post- 
operative hemorrhage. 

The administration of ether in measured dosage, as 
is the case when the Connell Anaesthetometer is employed, 
has brought to light an interesting and valuable fact. It 
has been found that once the patient is induced, once his tis- 
sues are saturated with ether, the percentage of ether 
necessary to maintain anaesthesia is about the same in all 
cases. For example, be the patient man, woman or child, 
approximately the same percentage of ether vapor will 
maintain each at about the same level of anaesthetic sleep 



342 ANAESTHESIA 

( see page 68 and Fig. 49 ) . So that when the anaesthetom- 
eter is employed the question of the age and the sex of the 
patient is of interest chiefly during the stage of induction. 
Where inhalation methods are employed, however, or any 
form of insufflation anaesthesia (page 152) other than that 
of the anaesthetometer, the maintenance which is variable 
by necessity must adapt itself to the individual patient. 
The underlying needs of the patient are the same in each 
case, but the method used does not meet these needs auto- 
matically, the dosage being influenced by the rate rhythm 
and the depth of the respiration. The maintenance of 
anaesthesia by the Connell anaesthetometer might well be 
compared to the replacement of the ordinary atmospheric 
air by an ether vapor whose density is absolutely safe as 
regards life, whose effects are non-accumulative, and which 
maintains the patient in a condition of unconsciousness 
and muscular relaxatk n. 

Briefly, then, with the proper methods at our disposal, 
ether is the anaesthetic of choice, regardless of age or sex. 
It may be preceded to advantage by preliminary morphine 
and atropine, nitrous oxide, nitrous oxide and oxygen, the 
C E mixture or ethyl chloride as occasion offers. The 
question of age and sex per so will not be an indication for 
the choice of any other agent where a complete general 
anaesthesia is necessary. Such indications, if present, will 
be found in the sections which follow. 

The Nature and the Site or the Operation 

When one has inquired into the age and the sex of the 
patient, the next most natural inquiry is the nature and the 
site of the operation. Is the operation to be for the inci- 
sion and drainage of an infection, for osteomyelitis, for 



SELECTION OF THE ANAESTHETIC 343 

an intra-abdominal condition, or for the open reduction 
of a fracture? If so, where is it? Is it a carbuncle of the 
back of the neck, or a cellulitis of a finger? Is it osteomye- 
litis of one of the bones of the face or one of the extremities? 
Is the intra-abdominal condition in the pelvis or upper 
abdomen? Is the fracture mandibular or a Colles? 

The nature of the operation, our first consideration, 
will usually indicate whether a complete anaesthesia with 
its accompanying general and complete muscular relaxa- 
tion is desirable or whether an incomplete anaesthesia with 
some muscular rigidity is permissible. 

For an incomplete anaesthesia in little children, chil- 
dren who are not sufficiently robust to accept a closed 
method, ether, ethyl chloride, or the C E mixture may be 
used. The removal of adenoids, the perforation of an ear- 
drum, or the opening and drainage of a superficial abscess 
illustrate the type of case under consideration. As was 
stated under the consideration of the age of the patient, 
ether is the anaesthetic of choice. While somewhat dis- 
agreeable, it is certainly the safest and most efficient anaes- 
thetic for these cases. No other agent should be used as a 
routine by the inexperienced. Incomplete anaesthesia in 
older children and in adults is best secured by the admin- 
istration of nitrous oxide and oxygen. This is without 
doubt the safest, most efficient and agreeable anaesthetic for 
such operations as : 

Incision and drainage ofsinfections of the head, neck* 
trunk and limbs. 

Removal of small superficial tumors. 

The reduction of simple fractures and dislocations 
which do not call for complete muscular relaxation. 

The extraction of teeth. 



344 ANAESTHESIA 

Amputations of macerated parts in military surgery. 

The control of accidental hemorrhage. 

When nitrous oxide and oxygen are employed they 
should always be administered with an apparatus capable 
of bringing about complete relaxation with ether, for it is 
impossible to declare beforehand whether the patient will 
need complete relaxation or not before the conclusion of 
the operation. The author has repeatedly been called to 
give a breath of laughing gas for an apparently simple 
condition which subsequently developed into an operation 
of some half hour's duration, requiring complete anaes- 
thesia. Incomplete anaesthesia may always be attempted 
with safety, but should promptly become complete if the 
nature of the operation or the patient's individual reac- 
tion warrants it. 

When the nature of the operation calls for a complete 
anaesthesia, complete muscular relaxation, this should be 
arrived at as soon as conditions permit. If, for example, 
a gall-bladder exploration is decided upon, it is worse than 
useless to prolong the operation by carrying the lightest 
anaesthesia possible. To employ gas oxygen alone in a 
case of this nature without a very special indication on the 
part of the patient, is to attempt an anaesthetic feat with 
small hope of success. For, while it may be possible to 
keep the patient quiet on the table, yet the relaxation neces- 
sary for a thorough examination will be wanting and the 
anaesthesia, while perhaps satisfactory from the anaesthe- 
tist's point of view, will not be so from the surgical point 
of view, even though the surgeon deceive himself into 
thinking it is. Complete general anaesthesia is the rule, 
incomplete anaesthesia the exception. The reaction of the 
patient as well as the nature of the operation determine 



SELECTION OF THE ANAESTHETIC 345 

these exceptions. The actual duration of the anaesthesia 
often prohibits the continuance of an incomplete an- 
aesthesia. It must become complete, or undesirable signs 
will manifest themselves, such as movement, retching, or 
vomiting. If such signs make their appearance, it is wiser 
to induce complete anaesthesia at once than to suffer these 
conditions to persist. One often sees an anaesthetist strug- 
gling with a patient in an attempt to hold him with a gas 
oxygen anaesthesia for a procedure in which it is absolutely 
contra-indicated; attempting to use a light, incomplete 
anaesthesia where relaxation is essential. It is often better 
judgment to forego the advantage of a recovery by crisis 
in order that the surgeon may be able to do better work. 
Familiarity with gas oxygen anaesthesia breeds a tendency 
to make use of it only in selected cases, instead of making 
a routine anaesthetic of it in an attempt to force all patients 
to accept it regardless of the nature and the site of the 
operation. The author at one time felt that the reverse 
was true, but he has learned the fallacy of this view-point. 
The use of ether in conjunction with gas oxygen is a differ- 
ent proposition. That is, if ether is used freely, not simply 
an occasional drop to increase the potency of the gas 
oxygen. A gas oxygen induction, an ether maintenance, 
and a gas oxygen recovery is an ideal anaesthesia for all 
adult cases. By this method the ether used during main- 
tenance may be practically all washed out by the gas 
oxygen during the stage of recovery. 

* Occasionally one meets a short, thick-necked man who 
has been a habitual smoker and who is more or less alco- 
holic. Nitrous oxide may fail to have its usual effect, and 
when ether is added even in small quantities it cannot 
be absorbed because of the persistent cough which it in- 



346 ANESTHESIA 

auces. This type of case had best be induced by chlo- 
roform on an open mask. When anaesthesia is induced it 
may be maintained by either a semi-open ether method, 
closed ether, or the C E mixture. 

The site of the operation will determine not only the 
agent best suited but the method of its application. 

Formerly head and neck cases were anaesthetized 
by chloroform when the anaesthetist was sufficiently 
expert. It was found more efficient and agreeable to both 
surgeon and anaesthetist, not to mention the patient as 
well. Brain operations, cleft palates, glands of the neck, 
and goitre were handled by chloroform vapor delivered 
by an apparatus somewhat similar to that described on 
page 156. This agent has been practically displaced by 
ether where an apparatus for insufflation methods is to be 
found. Intrapharyngeal insufflation with ether provides a 
safe, efficient and agreeable method for all of these condi- 
tions (page 153) . Where this is not possible, intrapharyn- 
geal inhalation may be used for all cases except small chil- 
dren, who are best handled by chloroform or C E 
vapor delivered through an oral tube or mouth gag. Glands 
of the neck, decompression operations, lacerations of the 
scalp, etc., in small children are best handled by the method 
described on page 144, in which ether vapor is delivered 
into a mask by means of oxygen or air. Plastic opera- 
tions on the face, advancement operations for strabismus, 
eye enucleations, iridectomies, cerebral decompressions in 
adults, tonsils and adenoids, deviated septum operations, 
goitre operations, glands of the neck, etc., are successfully 
handled by either intrapharyngeal insufflation (page 153) 
or intrapharyngeal inhalation (page 146). 

For tonsils and adenoids in adults, however, there is 



SELECTION OF THE ANESTHETIC 347 

nothing quite so satisfactory as chloroform vapor, adminis- 
tered as described on page 156. 

Operations for empyema in small children are best 
done under open or semi-open ether administration. The 
patient is allowed to recover as soon as the pleural sack is 
opened. Coughing usually begins at once. The pus is 
evacuated and the lung is expanded. 

In adults gas oxygen anaesthesia is very satisfactory. 
This anaesthetic must be used with care in these cases, how- 
ever, as several fatalities have occurred, probably through 
limiting the necessary supply of oxygen. If the patient 
does not respond quickly to the gas oxygen, ether and 
oxygen had best be substituted. The advantage of this 
method is that oxygen is in use throughout the anaesthesia. 

Ether should be the anaesthetic in all intra-abdominal 
work, preceded by nitrous oxide or nitrous oxide oxy- 
gen. If properly administered, a free airway maintained, 
and the correct table position employed, it will not be 
found necessary to abandon this agent for chloroform. 

Pelvic operations in male and female should be han- 
dled in the same manner. 

Cystoscopic examinations usually require a complete 
anaesthesia, the gas oxygen ether sequence being most sat- 
isfactory. The urine is secreted and may be collected 
during the course of an ether anaesthesia. This is easily 
demonstrated upon catheterization of the ureters. 

Suprapubic prostatectomies are best done under a 
complete ether anaesthesia. The abdominal muscles must 
be relaxed in order that the base of the bladder may be 
easily reached by the enucleating finger. Rectal opera- 
tions involving a dilation of the sphincter require ether an- 



348 ANAESTHESIA 

aesthesia. When the operation is for hemorrhoids, fissure, 
ischiorectal abscess, or examination, however, the stage of 
recovery with the use of gas oxygen may be begun very 
early. 

Plastic operations on the female external genitals, cur- 
ettage, repair of cervix, anterior and posterior colpotomy 
or repair of the perineum may be done under gas oxygen 
if the proper preliminary medication is given and the pa- 
tient is put in the lithotomy posture before the anaesthetic 
is started. Small quantities of ether may occasionally be 
required, but the anaesthesia in these cases can be essen- 
tially gas and oxygen. 

Operations on the extremities, fingers, or toes, where 
complete relaxation is not essential, may be done under 
gas oxygen. For example, amputations, osteomyelitis, for 
foreign bodies, for simple fractures, for the removal of 
growths, etc. But when it is necessary to reduce a dislo- 
cation or a fracture in the case of a muscular individual 
complete ether relaxation must be obtained. 

Specific Pathological Conditions Influencing the 
Course of the Anaesthesia 

Circulatory System. — Valvular insufficiency, fatty 
degeneration, fibroid changes of the heart muscle and myo- 
carditis, aneurisms and arteriosclerosis do not in themselves 
contraindicate a general anaesthetic. Neither does an ir- 
regular pulse, tachycardia or bradycardia. The first group 
consisting of organic changes and the second due to func- 
tional derangements are approached in much the same 
manner. The broad indications in these cases are first to 
lessen irritability by preliminary medication of full dosage, 
morphine, gr. %, atropine, gr. Viso? secondly to use the 



SELECTION OF THE ANESTHETIC 349 

least toxic anaesthetic agent possible, ether rather than 
chloroform, in order that the integrity of the heart muscle 
may not be further interfered with. Thirdly, and of the 
greatest importance, to induce anaesthesia by gas oxygen in 
such a manner that there will be no cyanosis or spasm of the 
respiration which may lead to an increased blood-pressure. 
Formerly chloroform was always the anaesthetic of choice 
in these cases, but a carefully administered gas oxygen 
ether anaesthesia with preliminary morphine has proved so 
satisfactory that we are inclined to recommend it as the 
method of choice. Where gas oxygen is not available, the 
C E mixture will be found satisfactory. Primary or sec- 
ondary anaemia is satisfactorily dealt with in the same 
manner. The advantages of oxygen in these cases are ap- 
parent. One will often be surprised tc note that a pulse 
which was markedly irregular before the anaesthesia was 
induced will settle down into a regular rhythm when in- 
duction is complete. Such arythmia is probably of sym- 
pathetic origin and disappears when this system comes 
under the influence of the anaesthetic. A previous medical 
diagnosis may thereby be sustained. Arythmical tachy- 
cardia in toxic goitre cases is a different proposition, how- 
ever. These cases are critically ill and are prone to die 
without warning. In addition to the choice of the anaes- 
thetic agent and method to be employed in cases with cir- 
culatory disturbances, the position of the patient on the 
table should be carefully considered (see page 38) for 
various positions available. 

Respiratory System. — The selection of the anaes- 
thetic when the respiratory system is actually diseased is 
fraught with danger. It is questionable, in view of the fact 
that general anaesthetics are largely excreted by the lungs, 



350 ANAESTHESIA 

whether intravenous or rectal methods offer much advan- 
tage over anaesthesia by the respiratory route. Preliminary 
medication in full dosage, followed by either gas oxygen, 
the C E mixture, or chloroform, should be chosen. Predis- 
posing conditions, which lead to postoperative pneumo- 
nitis, are well described by Whipple (Surg. Gyn. and 
Obst., Jan., 1918). "He (the patient) usually comes into 
the hospital too warmly dressed — many of the patients 
wear more than one suit of heavy underwear; he is given 
a hot bath and is either put to bed or allowed up and about 
the cool ward with far less clothing than he is accustomed 
to wear. During the twelve or twenty- four hours before 
operation, he may be examined in a more or less exposed 
condition, one or more times. He is given his preparatory 
shave and is exposed still more in the early morning hours 
as the result of catharsis and enemas. It may be that com- 
ing to or from the operating room he is exposed to cold 
draughts in the long corridors so characteristic of hospi- 
tals. During his recovery from the anaesthetic with his 
vasomotor system depressed he may become chilled, espe- 
cially if his bed-clothes do not cover his shoulders, and on 
the average neatly made hospital bed with blanket 
shrunken from repeated cleaning, the bed-clothes seldom 
come above the costal margin. A small shoulder blanket 
may or may not make up for the deficiency. Many of the 
patients are not accustomed to sleeping in a cold room and 
particularly under an open window. Too often the mod- 
ern interne or nurse with disdain for draughts and cool tem- 
perature, forgets that the twenty- four hours before or after 
operation is not the best time to correct habits and customs 
of a lifetime. The writer is firmly convinced from repeated 
observations in several hospitals, that one of the most im- 



SELECTION OF THE ANESTHETIC 351 

portant predisposing causes of post- operative pneumonitis, 
both in patients coming into the hospital with a recent cold 
or free from an active cold, is the exposure to which he is 
subjected during the first twenty-four to forty-eight hours 
of his stay in the hospital." 

Acute laryngitis, tonsillitis, or quinsy contra-indicate 
ether as the anaesthetic. Chloroform is the anaesthetic of 
choice. Empyema has been considered (page 347) . This 
particular condition is well handled by anoci- association 
(page 244). 

Sub-acute and chronic diseases of the respiratory sys- 
tem, such as chronic bronchitis, asthma, emphysema, or an 
old-standing pleurisy, tolerate ether anaesthesia well. As 
the available lung tissue has been reduced or interfered 
with in these conditions, the addition of oxygen to the 
ether mixture will be found beneficial. 

Ether in high concentration or administered for a long 
period is contra-indicated in pulmonary tuberculosis. Pre- 
liminary morphine and gas oxygen anaesthesia with enough 
ether to secure the necessary control is equal if not superior 
to chloroform. This becomes particularly desirable if gas 
oxygen is used for the stage of recovery and the ether used 
is well washed out of the circulation. Where gas oxygen is 
not available the C E mixture, chloroform or ethyl chlo- 
ride may be used. 

Gastrointestinal System. — Operations on the 
tongue, pharynx or oesophagus may best be done under 
ether administered by intrapharyngeal or intratracheal 
insufflation or inhalation. Gastro-enterotomies, resections 
of the pylorus, gall-bladder operations, operations on the 
large and small bowels, rectum and anus, are best done 
by a gas or a gas oxygen ether sequence, which has been 



352 ANAESTHESIA 

preceded by preliminary medication. Upper abdominal 
operations are among the most difficult to properly main- 
tain, but can always be controlled when proper attention is 
paid to the freedom of the respiration and the position of 
the patient on the table. The most difficult cases one meets 
with are those of intestinal obstruction, with distended 
guts. If the general condition is fair, induction should be 
brought about quickly by gas oxygen ether, in order to 
pass the vomiting level as soon as possible (see page 73). 
If the patient's condition is critical, the laryngeal reflexes 
should be retained by using a light gas oxygen anaesthesia, 
in order that the vomiting which will inevitably follow may 
not be inspired. These cases are trying and require ex- 
perience for their proper control. Preliminary gastric 
lavage may be practised, but it is obviously impossible to 
completely empty the stomach and keep it so. Ascites if 
pronounced may give rise to interference of the respiration 
by pressure on the diaphragm. These cases should be 
operated upon before they are completely induced. When 
the fluid is allowed to escape the general condition im- 
proves at once and induction may be completed. Gas 
oxygen anaesthesia is the best anaesthetic to employ up to 
the point of the escape of the fluid, when straight ether may 
be resorted to. Incarcerated hernias require relaxation for 
the best results, and for this reason are treated precisely 
as the ordinary abdominal operation. Enterostomies 
where intra-abdominal exploration is not done may be 
satisfactorily anaesthetized under gas and oxygen. The 
repair of ruptured gut is often done with no anaesthetic, 
owing to the insensibility of the visceral peritoneum to pain. 
When closure of the abdomen is attempted, however, it is 



SELECTION OF THE ANESTHETIC 353 

necessary to induce a complete anaesthesia if the wound 
is in the upper abdomen. 

Nervous System. — Among the disorders of the ner- 
vous system which may affect the course of the anaesthesia 
may be mentioned tumors of the cerebrum and cerebellum, 
hemorrhage, primary or secondary to fracture which gives 
rise to pressure, disorders which are purely temperamental, 
epilepsy, insanity and cord paralysis. 

Tumors and hemorrhage into the cranial cavity act 
mechanically by increasing the intracranial pressure. This 
pressure if sufficient to embarrass the respiration even 
slightly may be augmented by the anaesthetic to such a 
point that a fatal result ensues. The indication in these 
cases is to reduce all occasions of excitement during the 
induction of the anaesthetic. For this purpose prelim- 
inary medication and gas oxygen are used. Anaesthesia 
is best maintained by an intrapharyngeal method, pref- 
erably that of Connell (page 153). Where this is not 
available a simple inhalation method, such as is described 
on page 148 may be used. A case of this nature is nec- 
essarily a grave risk and must be approached as such. 
The author recalls a case in point who died spontaneously 
a few minutes before the anaesthetic was administered. 
This death, if occurring a short time later while the patient 
was being anaesthetized, would without doubt have been 
laid at the door of the anaesthetist. 

Temperament often plays a most important part in 
the course of the anaesthesia. The neurotic or hysterical 
man or woman will often have a stormy induction and an 
uneven maintenance, although treated exactly as his prede- 
cessor. The use of preliminary medication and a careful 
but rapid induction will often inhibit distressing reactions. 



354 ANAESTHESIA 

Rules have been laid down (page 82) concerning the signs 
of anaesthesia which one may normally expect. The neu- 
rotic individual will form the exception to these rules. The 
rate rhythm and amplitude of the respiration will con- 
stantly vary, rigidity will be more or less persistent, the 
eye signs will mislead, and even the pulse will occasionally 
be erratic. These conditions are particularly true of a light 
anaesthesia and tend to disappear as anaesthesia is deepened. 

An attack of epilepsy is sometimes brought on by an 
anaesthetic, particularly during induction. These attacks 
are occasionally seen where gas oxygen is the anaesthetic. 
Insanity and cord paralysis do not contra-indicate a gen- 
eral anaesthetic. 

Genito-Urinary System. — The presence of a mod- 
erate albuminuria associated with casts does not contra-in- 
dicate a general anaesthetic, if that anaesthetic is not per- 
mitted to remain in the tissues for excretion. Gas oxygen 
offers no contra-indication, as none of the anaesthetic re- 
mains for excretion by the kidneys. This is also true of 
ethyl chloride. If ether is used, however, it must be washed 
out of the tissues by gas oxygen in the manner described 
on page 224. If there is little or no ether on the breath at 
the end of the anaesthesia, we may be sure there is practi- 
cally none left in the tissues for excretion by the kidneys. 
Chloroform is in such cases decidedly contra-indicated. 

The method described above is the method of choice 
where only one kidney remains, following a nephrectomy, 
in tuberculosis of the kidney, renal or ureteral calculi. 

Pregnancy does not contra-indicate a general anaes- 
thetic. Pure nitrous oxide without oxygen should not be 
used, however, owing to the likelihood of inducing a 
miscarriage. 



SELECTION OF THE ANESTHETIC 355 

For obstetrical purposes, for eclampsia, for uterine 
hemorrhage from any cause, or for ruptured uterus, the 
anaesthetic of choice is gas oxygen, followed by oxygen 
ether by the closed method. Chloroform is efficient and 
agreeable, but is not safe from the point of view of post- 
operative degenerations (page 186) of the internal organs. 
Open drop or semi-open drop ether is safe, but neither 
efficient nor agreeable. Gas oxygen anaesthesia and nitrous 
oxide alone is now being widely used to minimize the pains 
of labor which occur during the stretching of the cervix. 
When the patient feels the onset of a pain she breathes 
deeply into a bag containing pure nitrous oxide gas. Three 
or four breaths of this mixture brings about a condition of 
analgesia which is an excellent substitute for the so-called 
"twilight sleep." The analgesia seldom becomes anaes- 
thesia in this case, consequently there is no effect whatever 
upon the foetus. The patient recovers her normal sensa- 
tions as the pain disappears. 

Extra-uterine pregnancy which has been followed by 
rupture offers one of the most striking examples of the 
advantages of gas oxygen or oxygen ether anaesthesia by 
the closed method. This patient comes to operation with 
lips which are either absolutely colorless or bluish and with 
a respiration which is scarcely audible. Five minutes after 
the induction of a gas oxygen anaesthesia, the lips and ears 
become pink and the respirations vigorous. The rebreath- 
ing stimulates the respirations and allows the patient to 
avail herself of abundant oxygen added to the respired 
mixture. These cases offer the most striking example 
of the beneficial and stimulating effect of an anaesthetic 
administered in this fashion. 

Patients with a high temperature due to various types 



356 ANAESTHESIA 

of infections, such as are seen in ruptured appendices, gall- 
bladders or gastric ulcers, are easily induced and main- 
tained, but are prone to respirations which are shallow, 
somewhat irregular and very rapid. These respirations will 
be found to be consistently between 50 and 60 a minute. 
It is almost impossible, moreover, to reduce the rate of 
these respirations without letting the patient come out of 
his anaesthetic. The characteristic ease of induction and 
rapid respirations has often caused the author to prognos- 
ticate sepsis before the belly was opened and the pus found. 
Limited rebreathing with an oxygen ether maintenance 
is indicated in these cases. 

Tuberculosis of the muscles, bones and joints is best 
anaesthetized by gas oxygen with a minimum use of ether. 

In operations for the relief of glaucoma anything 
should be avoided which might raise blood-pressure, such as 
protracted excitement, the use of nitrous oxide alone or an 
improper position on the table with obstructed respiration. 

Adenoidectomies, where the tonsils are not removed, 
may well be done under gas oxygen in adults, and an in- 
complete ether anaesthesia in small children. In these cases 
it is important to see that the posterior nares do not be- 
come filled with blood which may find its way through the 
Eustachian tube to the middle ear. This condition has 
been repeatedly demonstrated and should be guarded 
against by keeping the child on his face with his head 
somewhat elevated, thereby allowing the accumulated blood 
to escape. 

Operations for deviated septum and enlarged turbi- 
nates may best be done by intrapharyngeal inhalation ad- 
ministered through an oral tube as described on page 148. 

Operations for mastoid infections are satisfactorily 
treated in the same manner. 



STATUS LYMPHATICUS 357 

Status Lymphaticus 

Status Lymphaticus is occasionally diagnosed in chil- 
dren and even adults who are about to suffer operation. 
When this diagnosis is substantiated by X-ray showing 
an enlarged thymus, we have a positive and grave situation 
to meet. These patients often die from the slightest pro- 
vocation. Chloroform as a general anaesthetic and adren- 
aline as an adjuvant to local anaesthesia should be carefully 
avoided. 

Pediatricians who meet this condition in young children 
are unanimous as to the danger. Kerley recommends that 
operations be done as rapidly as possible under gas oxygen 
anaesthesia. He recalls one death on the table and two 
near fatalities. Roland Freeman advises two or three X- 
ray treatments to reduce the size of the thymus before 
operation. Anaesthesia may then be administered with 
greater safety. A recent case of glands of the neck in a 
child so treated passed through the ether anaesthesia admin- 
istered without ill effects. C. N. Dowd who performed 
this operation reports a death on the table which on autopsy 
proved to be sarcoma of the thymus. T. D. Buchanan 
reports a case in which a child with a definite thymus was 
anaesthetized three times without ill effects. The author 
recalls two definite cases presenting an enlarged thymus 
which he successfully anaesthetized. In his practice, as 
in that of every other anaesthetist, there have doubtless been 
many thymus cases anaesthetized in which no diagnosis 
was made. The last case anaesthetized on January 29, 
1922 was that of a girl ten years of age of a typically sera- 
phic countenance. The operation was for tonsils and ade- 
noids. She came to the anaesthetizing room expressing 



358 ANESTHESIA 

all the hysterical anxiety of the toxi goitre case. Some 
dyspnoea and hoarseness were present. Anaesthesia was 
induced with gas and oxygen, passing to ether oxygen. 
When fully induced, the anaesthesia was maintained by 
intrapharyngeal insufflation. The anaesthesia was abso- 
lutely smooth. No cyanosis or symptoms of obstruction 
appeared. Care was exercised to avoid over extension of 
the head, as this position by raising the thymus has a ten- 
dency to compress the trachea between it and the sternum 
effectually strangling the patient. 

Synergistic Anaesthesia 

According to Meyer and Gottlieb (Pharmacology, 
Clinical and Experimental — 1914, Page 82). 

"If the weakening or the prevention of the action of 
one drug by that of another be called antagonism the one 
sided or reciprocal augmentation of such action may be 
called synergism. 

Synergistic anaesthesia therefore is the anaesthesia which 
results in combining various drugs. 

Metzer (American Journal E. Medicine, 1916, Vol. 
23, p. 641) found that magnesium sulphate can be used as 
a general anaesthetic if in j ected intravenously into the cir- 
culation. 

Gwathmey has recently developed synergistic anaes- 
thesia to an interesting degree. Using magnesium sulphate 
hypodermatically as an adjuvant to ether and nitrous 
oxide and oxygen. His technique is as follows: 

15 grains of chlorotone are given two hours before 
operation — 15 minutes later a hypodermolysis of 300-400 
c.c. of sterile chemical pure 4% magnesium sulphate at 
a temperature of 110 is given; J / 2 hour being consumed in 



SYNERGISTIC ANESTHESIA 359 

this administration. Morphine is given in doses of V 8 grain, 
repeated three times. 

The patient arrives in the operating room well narco- 
tized; aroused with difficulty; he usually sleeps all day 
without further medication and frequently all night. 

In view of the fact that magnesuim sulphate is a dis- 
tinct respiratory depressant, the use of this drug combined 
with chlorotone and three yi grain of morphine as a 
preliminary to ether or nitrous oxide and oxygen is 
fraught with danger. When we see troublesome respira- 
tory depression, which appears only after the start of the 
general anaesthetic from V 4 grain and from 1 / 6 grain of 
morphine, how can we look upon the routine use of 3 / 8 
grain to which has been added the depression from the 
magnesium sulphate? 



360 ANESTHESIA 

Chart for 

Preliminary Medication by Morphine and 

Scopolamine 

Patients may be divided into three classes based upon 
resistance to the anaesthetic: 

Class A. — Weight under normal. Septic or anaemic. 
Over sixty years of age. 

Class B. — Normal weight. Average physique. Under 
sixty years of age. 

Class C. — Weight above normal. Athletic or massive 
physique. Under sixty years of age. 

Solution for hypodermic use to contain morphine sul- 
phate gr. V4 and scopolamine hydrobromide (not hyos- 
cine) gr. 1/100 to each 20 minimums of solution. 

One hour before estimated time for operation. 

Class A. to receive 10 m. of solution (gr. V 8 -l/200) 

Class B. to receive 15 m. of solution (gr. 1 / 6 -l/150) 

Class C. to receive 20 m. of solution (gr. V4-I/IOO) 

If the patient upon his arrival to the operating floor 
appears alert, fidgety or anxious he is to receive a second 
dose as follows: 

Class A. 10 m. 

Class B. 10 m. or 15 m. depending upon reaction to 
previous dose. 

Class C. 15 or 20 m. depending upon reaction to pre- 
vious dose. 

The purpose of preliminary medication is to render 
the patient susceptible to the general anaesthetic and to 
secure a condition of semi-consciousness and mental apathy. 



■ 



APPENDIX 

ARTIFICIAL RESPIRATION AND RESUSCITATION BY 
THE MELTZER METHOD 

The Meltzer method of artificial respiration is based 
upon the principle of pharyngeal insufflation, a process 
that consists in expanding the lungs with air at regular 
intervals of about 12 to the minute and depending on the 
elasticity of the chest walls to expel a portion of the air 
during each intervening period. In using the apparatus, 
a board is first strapped tightly over the abdomen (Fig. II ) 
to prevent the stomach instead of the lungs from being 
expanded with the air. 

The pharyngeal tube attached to the apparatus is then 
placed in the mouth and pushed as far back as it will go 
( Fig. Ill ) , and the tongue is drawn forward and tied to 
the tube (Fig. II). The tube pushes the soft palate up- 
ward and effectually closes the passageway through the 
nose (Fig. Ill) so that no air can escape through the nos- 
trils, while an opening in the bottom of the tube permits 
the air to pass freely down the throat. 

For supplying the air, a foot bellows is used ( Fig. I ) , 
As the air is conducted through the tube it passes a valve 
(3) which regulates the inspiration and expiration. With 
watch in hand, or in synchronism with his own respiration, 
the attendant turns the ring that governs this valve alter- 
nately to the right and left at regular intervals. 

When the ring is turned to the right the air is forced into 
the lungs, and when the ring is turned to the left the air 
is shut off, at the same time a small vent is opened and the 

36i 



362 



APPENDIX 



Artificial Respiration and Resuscitation 

~ Meltzer Method - 

GEO. TIEMANN 6c CO ~~~ NEW YOR 




Broken line showes 
shorn a ch rube in place, 
which is necessary only 
when abdominal pressure 
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APPENDIX 363 

air escapes from the lungs. Just below this valve is one 
for regulating the pressure of the air given the patient 
(5-Fig.I). 

At the start the pressure used is very low, but is in- 
creased by gradual closing of the valve, until the chest 
shows a regular normal heaving. 

In case the apparatus is hurriedly called into use during 
an abdominal operation, in which case the abdominal board 
(1) cannot be strapped on, a stomach tube is passed 
through the pharyngeal tube, through the oesophagus and 
into the stomach (Fig. III). 

An important feature of the apparatus is that it can 
be operated by one man, who need not be an expert. The 
bellows is worked by the foot and the respiratory valve is 
operated by the right hand, leaving the left hand free for 
making any adjustments that may be necessary. 

For a complete description of this method see Medical 
Record, July 7, 1917. 



BIBLIOGRAPHY 

CARBON DIOXIDE AND REBREATHING 

Gatch, W.: Nitrous Oxide Oxygen Anaesthesia by the 

Method of Rebreathing, Journal A. M. A., 

March 5, 1910, p. 775. 
The Use of Rebreathing in the Administration of 

Anaesthetics, Nov. 11, 1911, p. 1593. 
Rovsing: Abdominal Surgery, Clinical Lectures for 

Students and Physicians. Translation by Pilcher, 

Philadelphia, 1914. 
Henderson- Yandekl : 1. Am. Jour. Physiology, 1909, 

24; 66. 

2. Acapnia and Shock (seven papers), Am. Jour. 
Physiology, 1908-1913. 

3. Respiratory Experiments on Man. The Jour. 
A. M. A., April 11, 1914, p. 1133. 

4. Tr. Am. Gynec. Soc, 1914. 

5. Surg., Gynec. and Obstetrics, 1914, p. 386. 

6. Shock After Laparotomy ; Its Prevention, Produc- 
tion and Relief. Am. J. Physiol., 1909, 21, 60. 

7. Fatal Apncea and the Shock Problem. Johns 
Hopkins Hospital Bulletin, Aug. 1910, 21, No. 233. 

Barcroft: Respiratory Function of the Blood. Cam- 
bridge, 1914. 

Bryant and Henderson : Closed Ether and a Color Sign. 
Jour. A. M. A., July 3, 1915, p. 1. 

Levi Ettore : Studies on the Patho-Physiologic Action of 
C0 2 and on the Therapeutic Applications in Sur- 
gery and Medicine of Mixture of (O) and C0 2 . 
Estr. d. rev. di. clin. med., 1910, 11, 30, 31. 

36 5 



366 ANESTHESIA 

Hill and Flack: The Effect of Excess of Carbon 

Dioxide and a Want of Oxygen on the Respiration 

and the Circulation. Jour. Physiol., June 30, 1908. 
Crowder, T. R. : A Study of the Ventilation of Sleeping 

Cars. Arch. Int. Med., Jan. 15, 1911, 85. 
Haldane and Smith: The Physiologic Effects of Air 

Vitiated by Respiration. J. Path, and Bact., 1892 

and 1893, 1, 168, 318. 
Erclents Flugge: Report of Experiments at the Insti- 
tute of Hygiene at Breslau. Z. f. Hyg., 1905, 363, 

388, 405, 433. 
Hill and Walker : The Relative Influence of the Heat 

and Chemical Impurity of Close Air. J. Physiol., 

Nov. 9, 1910. 
Caldwell and Cleveland : Observations on the Relation 

of Acidosis to Anaesthesia. Surg. Gyn. and Obst., 

July, 1917. 
Connell, Karl: Compressed Air for Operating Room 

and Emergency Use. Int. Hosp. Record, Nov., 

1912. 
An Apparatus, Anaesthetometer, for Measuring and 

Mixing Ansesthetic and Other Vapors and Gases. 
Surg. Gyn. and Obst., August, 1913. 
Meltzer: History and Analysis of Methods of Resusci- 
tation. Medical Record, July 7, 1917. 



INDEX 



Abdominal distention, 29 

Abnormal amplitude during maintenance, 88 

rate during maintenance, 86 

respiration due to Trendelenburg posi- 
tion, 89 

rhythm during maintenance, 87 
Abnormalities of respiration in recovery, 89, 

90 
Acapnia, 299 

Adenoids, obstruction from, 26 
Administration, method of, 334 
Alcohol chloroform ether mixture, 191-193 
Amplitude of respiration, 86-88 
Anaesthesia by anoci association, 244-248 

age and sex in regards to, 338 

place of, 18 

preliminary medication in, 277-284 

signs of, 82 
Anaesthetic and asthma, 35 

and pneumonia, 35 

for goitre cases, 35 

history, 16 

period, 4-6 

selection of, and method of administra- 
tion, 334 
Anaesthetist's records, 318-320 
Anoci association, 244, 248 
Apparatus, Bennett, 137 

Connell, 153 

Flagg, 131-136 

Miller, 230 
Artificial respiration, 90-97 
Aspirating tongue depressor, 327 
Aspirators, 321-327 
Asthma with anaesthesia, 35 
Atropine and morphine preliminary to anaes- 
thesia, 277-284 

Bennett apparatus, 137 

method, 131-138 
Brachial paralysis, 41-42 
Breathing tube, 33, 34, 317 
Bromides preliminary to anaesthesia, 277 

Carbon dioxide and cyanosis, 298, 299 
and rebreathing, 296-307 
chemistry of 297, 298 
effect of increasing amount in blood, 
300, 301 



Carbon dioxide, effect of reducing amount in 
blood, 299 
in the blood, 297, 298 
origin of, 297, 298 
percentage to cause dyspnoea, 296 
percentage to stimulate respiration, 
296 
Cardiac massage, 119 
Cerebral hemorrhage, 88 
Cheyne-Stokes respiration, 88-90 
Chloroform, 185-200 

administration of, 194 
anaesthesia, apparatus for, 194, 195 
causes of death in, 195-197 
general considerations of, 200 
mortality in, 200 
position for, 197-200 
present status of, 190-192 
signs of, 197-199 
containers for, 194 
delayed poisoning with, 186-192 
ether anaesthesia, 193 
poisoning, pathology of, 186-192 
testing quality of. 310 
vapor, oral insufflation of, 199 
Circulatory shock, 292 
Closed drop method, 130 

administration, 133 

as compared with open and 

semi-open drop, 138 
requirements for, 130 
Coaxing the reflexing, 20 
Cocaine solution for local anaesthesia, 256 
Coccygeal operations, position for, 43 
Combined general and local anaesthesia, 244- 

248 
Complete anaesthesia, curve of , 12 

stages of, 11 
Conductive anaesthesia, administration, 259 
Constant maintenance, control of, 71 

pressure of vapor delivered, 70 
volume employed in, 70 
Containers for nitrous oxide, 201, 202 
Control of vomiting, 79 
Color signs, 97-102 

with closed method, 99-101 
with jaundice, 101 
with negroes, 101 
with open method, 99 

367 



INDEX 



Conjunctivo-palpebral reflex, 106 
Corneal reflex, 106, 107 
Cyanosis and carbon dioxide, 298, 299 
postoperative, 289 

Degeneration of liver with chloroform, 186- 

192 
Deviated septum, obstruction from, 26 
Diaphragmatic sign, 104 
Diet, postoperative, 295 

preliminary, 17 
Diffusible solution, 262 
Dilatation of sphincters, 28 
Distention, abdominal, 29 
Driving the reflexes, 20 
Drop bottle, 124 
Duties of nurse after anaesthesia, 287 

before anaesthesia, 285-287 

during anaesthesia, 287 

Emergency anaesthesia, 308-318 
accessories to, 317 
chloroform in, 314 
ethyl chloride in, 314 
Endoneural injection, 260 
Erb's palsy, 41 

Esmarch's bandage, anaesthesia with, 251 
Estimating amount of nitrous oxide in 

cylinder, 202 
Ether, absorption of, 66 

administration of, 121 

by inhalation method, 122 
anaesthetia, zones of, 72 
cone, 311-313 
effect on viscera, 189, 190 
frolics, 4 
intravenous administration of, 174— 

180 
per rectum, 169 

preparation for rectal administra- 
tion, 169 
properties of, 120 
rectal administration of, 172 
saturation, 26 

solution for intravenous adminis- 
tration, 311-313 
tension, in body, 69 
testing quality of, 309 
vapor tension of, 64 
Ethyl chloride, 181-184 

administration of, 183, 184 
anaesthesia, sequelae of, 183 
apparatus for, 183 
dangers of, 184 
freezing with, 249, 250 



Ethyl chloride, properties of, 181 
Excitement in induction, 19 
Eyelid signs, 103 
Eye sign, 105 

Facepiece for open drop method, 123 
First surgical anaesthesia, 4 
Flagg apparatus, 131-136 

anaesthesia with, 133 

features of, 132 

induction with, 133 

maintenance with, 134 

recovery with, 135 

vaporization in, 132 
method, 133-136 
Freezing with ethyl chloride, 249, 250 

Gall-bladder position, 43 
General anaesthesia, classes of, 11 

definition of, 9 

degrees of, 11 

production of, 9 
Glottis, oedema of, 26-34 
Goitre cases with anaesthesia, 35 
Gwathmey method of rectal anaesthesia, 171 = 

173 
Haemoxometer, 96, 219 
Hemorrhage, 291 

cerebral, 88 
Henry's law, 65 
History of anaesthesia, 1-6 
Hypercapnia, 299 
Hypodermoclysis, technic of, 117 
Hysteria, 292, 293 

Improvised breathing cone, 311-313 
Improvised breathing tube, 317 
Incomplete anaesthesia, 13 

curve of, 13 
Induction, 15 

period of, 15 

time of, 12 
Infiltration anaesthesia, administration of, 258 
Infusion, technique of, 114 
Inhalation, oral, vapor method of, 143 

intrapharangeal, 146 

intratrachael, 149 
Insufflation, 152 

oral, 152 

intratracheal, 153 
Intra-abdominal administration of saline, 317 
Intrapharyngeal inhalation, 146 

insufflation, 154, 157 

administration, 154-157 
apparatus for, 153-156 
contra-indication, 158 



INDEX 



Intrapharyngeal inhalation, difficulties of, 167 

improvised, 314, 315 
insufflation, indications for, 158 
Intratracheal inhalation, 149 
insufflation, 159-169 

administration, 163-167 

advantages of, 168 

apparatus for, 161-163 

difficulties of, 167 

disadvantages of, 168 

improvised, 315, 316 
Intravenous anaesthesia, 174-180 

administration of, 177-179 

advantages of, 179 

apparatus for, 176 

disadvantages of, 179, 180 

ether solution for, 175 

postoperative treatment in, 179 
Intubation, technic of, 164, 165 

Jackson laryngoscope, 163 
Jaundice in anaesthesia, 101 

Kidney position, 43 

Kuatzu method of resuscitation, 119 

Laryngoscope, Jackson's, 163 

Lewis' pendulum swing, 95 

Lid reflex, 103, 105, 106 

Liquid method of oral inhalation, 123 

Lithotomy position, 53 

Liver, fatty degeneration with chloroform, 

186-192 
Local anaesthesia, 249-260 

by freezing, 249 

by pressure, 250, 251 

definition, 9 

needles for, 257 

preliminary treatment for, 257, 258 

production of, 9, 10 

solution of cocaine for, 256 
novocaine for, 256 
quinine and urea for, 256 

syringe for, 257 

unusual methods of, 249-254 

usual methods of, 255-260 

Maintenance, 59-6 

constant, 60 

control of, 61-63 

curve of, 60—64 

vapor tension necessary for, 67 

variable, 60-61 
Masseteric sign, 102 

spasm, 290 



Meltzer method, respiration and resusci- 
tation by, 357 
Methods of anaesthesia, Bennett, 136-138 

Flagg, 131-136 

Gwathmey, 171-173 

Miller, 230 
Mixed anaesthesia, 9, 10, 261, 273 

administration, 265-273 

advantages of, 271 

apparatus for, 263 

definition of, 9 

disadvantages of, 273 

general considerations of, 261-265 

production of, 10 

treatment of overdose, 268 
Morphine and atropine preliminary to anaes- 
thesia, 277 
contra-indicated, 284 
indicated, 284 

scopolamin preliminary to anaes- 
thesia, 277, 281, 284 
Mortality in chloroform anaesthesia, 200 
Mouth wedge, 33 
Mucus, removal of, 34 
Muscular signs, 102 
Musculospiral paralysis, 41, 42 

Neck operations, position for, 47 
Needles for local anaesthesia, 257 
Negative ventilation, 91 
Nitrous oxide, administration, 207, 208 
apparatus, 131, 136 
containers for, 201, 202 
preparation of, 203-206 
oxygen anaesthesia, 214-222 

characteristics of, 21 6 
color in, 218 
eye signs in, 221 
physical signs in, 218-221 
preliminary medication in, 

283 
pulse in, 221 
relaxation in, 220 
zones of, 234 
administration of, 218 
ether anaesthesia, 223-248 
administration, 224-235 
by constant flow, 230- 

233 
intermittent flow, 225, 
229 
difficulties in, 227, 229 
resume of 100 cases, 236- 
244 
Nondiffusible solution, 262 



370 



INDEX 



Normal respiration with ether and nitrous 
oxide, 84 
with open method, 83 
Novocaine solution for local anaesthesia, 256 
intravenous injection of, 251, 252 

Obstructed respiration, causes of 26 

control of, 32 
(Edema of the glottis, 26, 34 
Olfactory vomiting, control of, 79 
Open drop method, 123-127 

administration of, 125 
advantages of, 126 
apparatus for, 123 
disadvantages of, 127 
drop bottle for, 124 
facepiece for, 123 
in large clinics, 139-143 
Operation, nature and site of, 342 
Oral inhalation, methods of, 122 

vapor method, 143 
Orbital signs, 108 

Oxyhaemoglobinometer, 96, 226, 228 
Paralysis, brachial, 41, 42 
Erb's, 41 

musculospiral, 41, 42 
peroneal, 36 
Parson's sign, 108 
Pathological condition, specific, influencing 

course of the anaesthesia, 348 
Patient, point of view of, 328-333 
Period of excitement, 15 

control of, 19 
of relaxation, 57 
Periods of induction, 1 ' 
Peroneal paralysis, 36 
Pneumonia and anaesthesia, 35 

post-operative, 295 
Polypi, obstruction from, 26 
Positive ventilation, 92 
Postoperative cyanosis, 289, 290 
diet, 295 

hysteria, 292, 293 
pneumonia, 295 
treatment of goitre cases, 295 
vomiting, 288, 289 
Position for closure of abdominal wound, 53 
coccygeal operations, 43 
local operations, 43 
neck operations, 47 
rectal operations, 43 
Simms, 40 

Trendelenburg, 36, 39 
Walcher, 53 
Pre-an<esthetic period, 1-4 



Preliminary diet, 17 

medication in anaesthesia, 17, 277-284 
nitrous oxide anaesthesia, 283 
visits, 16 

use of morphine, 58 
Pressure guage, 92-95 
Protracted unconsciousness, 293, 294 
Pseudo-relaxation, 57 

rigidity, 25-29 
Pupillary signs, 109-113 
in induction, 110 
in maintenance, 110-112 
in recovery, 112, 113 
Pulmonary embolus, 88 
Pulse in nitrous oxide anaesthesia, 221 
rate, 114 
rhythm, 113 
signs, 113-119 
volume, 114 

Quinine and urea for local anaesthesia, 256 

Rapid induction, conditions necessary for, 68 
Rate of recovery, 294 

respiration, 86 
Rebreathing, 296-307 
Records, 318-320 
Recovery, 74-81 
by crisis, 75 
by lysis, 75 
control of, 76-81 
evidences of, 74 
in diabetes, 75 
room, 295 
stage of, 74 
types of, 75 
Rectal administration of ether, 169-174 
advantages of, 173, 174 
apparatus for, 171 
preliminary treatment for, 171 
solutions used in, 171 
Regional anaesthesia, administration of, 259 
intravenous injection of novocaine, 
251, 252 
Relaxation, causes of, 58 
control of, 59 
evidences of, 57 

in nitrous oxide oxygen anaesthesia, 220 
of upper eyelid, 103 
Removal of throat tube, 77 
Respiration, artificial, and resuscitation, 357 
Respiratory abnormalities, 85-88 
during induction, 85 
maintenance, 86 
in amplitude, 86, 88 



INDEX 



371 



Respiratory abnormalities, in rhythm, 85, 87 

failure, 291 

symptoms, 82 
Restraint during induction, 22 
Resuscitation, Kuatzu method of, 118, 119 

by Meltzer method, 357 
Rigidity, 24-35 
Rigidity, causes of, 25 

control of, 32 

Crile's theory of, 30 

evidences of, 24 

from dilatation of sphincters, 35 

from intra-abdominal distention, 56 

in gall-bladder cases, 28, 35 

in induction, 24 

in pelvic operations, 28, 35 
Rose position, 53 

Saliva, removal of, 34 

Saturation with ether, 26 

Scopolamin and morphine preliminary to 

anaesthesia, 277, 281, 284 
Semi-open drop method, 127-130 

advantages of, 129 

apparatus for, 128 

disadvantages of, 130 
Shock, 292 
Shoulder braces, 36 
Signs of anaesthesia, 82 

color, 97, 102 

diaphragmatic, 104 

eye, 105 

eyelid, 103 

masseteric, 102 

muscular, 102 

orbital, 108 

pupillary, 109, 113 
Signs of anaesthesia, Parson's, 108 

pulse, 113-119 
Simms' position, 40 
Spasm of vocal cords, 34 
Special senses during induction, 22 
Sphincters, dilatation of, 28 
Spinal anaesthesia, 261-273 

administration of, 265-268 

advantages, 271 

apparatus for, 263 

disadvantages of, 273 

general considerations of, 261-265 



Spinal anaesthesia, treatment of overdose, 268 
puncture, treatment of, 265-268 

Stage of induction, 11 
of maintenance, 12 
of recovery, 12, 74 

Stages of anaesthesia, 11 

Stopping anaesthesia, 77 

Sylvester method of artificial respiration, 91, 
92,94 

Syringe for local anaesthesia, 257 

Tension of ether in body during anaesthesia, 

69 
Terminal anaesthesia, administration of, 258 
Throat tubes, 33, 34 

removal of, 77 
Tongue depressor and aspirator, 327 
Tonsils, obstruction from, 26 
Trendelenburg position, 36-39 

contra-indications, 39 

dangers of, 39 

effect on respiration, 39 

indications for, 39 

pulse in, 77 
Turbinates, obstruction from, 26 
Types of anaesthesia, 9 

Urea and quinine in local anaesthesia, 256 
Unconsciousness protracted, 293, 294 

Vaporization, 64 

physics of, 64, 65 
Vapor method of oral inhalation, 143-145 
apparatus for, 144, 145 
ether administered by, 145 
Vapor tension of ether, 64 
Ventilation, negative, 92 

positive, 92 
Visit, preliminary, 16 
Vocal cords, spasm of, 34 
Vomiting, control of, 79 

olfactory, 79 

postoperative, 288, 289 
Vomitus, removal of, 34 

Walcher position, 53 

Zones of ether anaesthesia, 72 

Zones of nitrous oxide oxygen anaesthesia, 234 



P j V 



4V: 



